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A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 17e22
A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy* Shan Shan Jing*, Trevor O’Neill, Jonothan J. Clibbon Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK Received 5 June 2013; accepted 14 August 2013
KEYWORDS Fistula; Pectoralis major; Laryngectomy; Radiorecurrent; Gracilis
Summary Introduction: Muscle flaps are often used in the prevention and treatment of pharyngocutaneous fistula following total salvage laryngectomy in the setting of chemo-radiated neck for laryngeal carcinomas. We report our experience with the gracilis free muscle flap compared to the pedicled pectoralis major for the prophylaxis of fistula formation. Methods: Forty-nine patients with radio-recurrent laryngeal carcinoma over ten years who underwent salvage laryngectomy and either immediate free gracilis (22 patients) or pedicled pectoralis major muscle flap (27 patients) reconstruction were reviewed. Results: There were 12 complications in pectoralis major flap group and eight in gracilis flap group. Most of these occurred early in the post-operative period. These were related to poor wound healing with the pectoralis major flap reconstructions. Fistulation rates were similar in the two groups (Pectoralis major: 6/27, gracilis: 5/22). Conclusions: In our experience, the gracilis free muscle flap is a good reconstructive option in the prevention of pharyngocutaneous fistula formation following salvage laryngectomies. It is at least equivalent to a pectoralis muscle flap in the prevention of fistulae, but we prefer the gracilis for many reasons, including ease of harvest and preservation of the pectoralis major flap for future reconstructions. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Previous presentations: This original paper has been previously presented at Doctors Update Meeting in Val D’Isere, 30th January 2012 and at the 5th European Head and Neck Society Meeting in Poznan, 21st April 2012. * Corresponding author. E-mail address: [email protected] (S.S. Jing).
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.018
18
S.S. Jing et al.
Introduction The development of a pharyngocutaneous fistula (PCF) remains the most common and challenging complication following total laryngectomies. It leads to delays of the adjuvant treatments and prolonged hospitalization. The incidence of fistula reported in the literature is variable, ranging from 5% to 65%.1,2 Causative factors associated with its formation have been extensively studied. These include the age and sex of the patients, medical comorbidities, patients’ smoking status, tumour site and stage, preoperative tracheostomy, concurrent neck dissections, surgical closure techniques, and the peri-operative haemoglobin level.1,2 However, the significance of these factors remains controversial. In the recent years, the treatment of laryngeal cancers has moved away from primary laryngectomy towards organ preservation, with the use of initial chemoradiation followed by salvage laryngectomy for subsequent disease recurrence.3 This change in practice has led to a significant increase in the incidence and severity of fistula development.2e4 PCF following radiotherapy and laryngectomy occurs 2.6 times more frequently than compared to primary laryngectomy alone.5 The additional use of chemotherapy is associated with a further 2 fold increase in the fistula rate.3,6 The timing of chemoradiotherapy to surgery and the dosage adds further implications.3,7 As a result, some authors have advocated for flap reconstruction at the time of laryngectomy in an effort to reinforce the primary pharyngeal suture line with vascularized tissue to prevent fistula formation.3,8,9 Repair of an established fistula is associated with more complications and poorer outcomes.10 First popularized by Ariyan (1979), the pedicled pectoralis major muscle flap (PMMF) has been the workhorse flap for this indication.11 It is robust and locally available, but can carry a reasonably high complication rate (36.1%).4,12,13
Microvascular free flaps such as the radial forearm flaps and anterolateral thigh flaps have also used.9,14 The outcome of the pedicled and free muscle flap has not been formally reported. Gracilis free muscle flap (GFMF) is not widely used in head and neck reconstructions, but it has the potential to give excellent results. It is a vascularized tissue with a reliable pedicle anatomy, good plasticity and low donor site morbidities. Table 1 illustrates its advantages. This study reports our experience of using the GFMF reconstruction compared to the PMMF in buttressing the pharyngeal suture line to prevent fistula formation at the time of salvage laryngectomy for radiorecurrent laryngeal carcinomas.
Patients and methods Between May 1999 and March 2011, 49 salvage total laryngectomies without concurrent pharyngectomy and immediate GFMF or PMMF flap reconstructions for radiorecurrent laryngeal squamous cell carcinomas following failed primary chemoradiotherapy at a single tertiary unit were reviewed. The reconstructions were performed by experienced surgeons using a similar laryngectomy closure technique.
Surgical technique Pedicled pectoralis major muscle flap reconstruction With the patient lying supine, the pedicled pectoralis major muscle flap was raised through an oblique incision on the anterior chest wall in a defensive approach preserving the detopectoral flap. The skin was raised above the pectoralis major muscle fascia. The muscle was then released from its lateral and inferior attachments and dissected off the chest wall from lateral to medially in the submuscular plane until it was islanded around a pedicle which coursed on its under
Table 1 Advantages and disadvantages of pedicled pectoralis major muscle flap compared to the free gracilis muscle flap for the reinforcement of primary laryngectomy closure following salvage total laryngectomy. Features
Pectoralis major muscle flap
Gracilis free muscle flap
Advantages
Reliable Robust
Reliable Good volume and size for buttressing laryngectomy closure Can be harvested with skin paddle Lower donor site morbidity Better aesthetic outcome than pedicled pectoralis major muscle flap Allows the flap to be raised simultaneously to the laryngectomy
Good volume for buttressing laryngectomy closure Can be harvested with skin paddle
Disadvantages
Potential respiratory compromise Poor aesthetic outcome e scar on chest, muscle bulge over clavicle, potential distortion of breast in female patients, split thickness skin graft may be required. Reduced neck movement Can not be raised simultaneously to laryngectomy Limited arc or rotation and transposition
Microsurgery required Postoperative monitoring is difficult as it is a buried flap.
Comparison between free gracilis MF and pedicled PMF reconstructions
19
Figure 1 This illustrates the pedicled pectoralis major muscle flap being raised from the anterior chest wall in the sub-muscular plane with the pedicled running on its undersurface.
surface (Figure 1). The pedicled muscle flap was transposed under the skin bridge and pivoted over the clavicle (Figure 2). It was laid over the laryngectomy closure site and secured to the base of the tongue superiorly, sternocleidomastoid muscles laterally and to the apex of the tracheostomy site inferiorly (Figure 3).
Figure 3 The pedicled pectoralis major muscle flap is positioned over the primary closure of the defect following a salvage total laryngectomy.
Free gracilis muscle flap reconstruction With the patient was positioned supine, an axial incision from the pubic ramus to the mid thigh was made. The muscle was harvested in a distal to proximal and posterior to anterior approach from the adductor compartment. Distal perforators to the muscle were divided and the pedicle was identified. The gracilis muscle was released from its tendinous origin (Figure 4). Suitable recipient vessels were identified in the neck for microvascular anastomosis (Figure 5). A venous coupler was used for the veins where possible. The muscle was secured in the same
manner as the pedicled pectoralis major flap over the closure of the laryngectomy defect. Post-operatively, patients were commenced on nasogastric tube feed until a routine contrast swallow test was performed on day 10 to exclude a radiological leak. If no leak was identified, the patients were then commenced on oral intakes; otherwise, patients remained on the enteral feed until they had passed subsequent swallow tests. The mean follow-up was 24 months. Complications that occurred within 30 days following surgery were recorded as early and thereafter were recorded as delayed. Statistical analysis using Chi square test of association and Fisher’s exact 2-tailed probability test were performed.
Figure 2 This illustration shows the pedicled pectoralis major flap under a cutaneous tunnel prior to transfer and flap inset.
Figure 4 This illustrates the free gracilis muscle flap being raised through an open approach with the pedicle still attached simultaneous to the total laryngectomy.
20
S.S. Jing et al. Table 2 Demographics of the 49 patients who had pedicled pectoralis major muscle and free gracilis flap reconstruction following salvage laryngectomy for radiorecurrent disease and laryngeal cancer stage (TNM staging system).
Figure 5 The free gracilis muscle flap is anastamosed to the facial artery and vein before it is positioned over the primary closure of the total laryngectomy defect.
Results Over a period of 11 years and ten months, 27 patients underwent PMMF flap reconstructions and 22 had GFMF flap reconstructions. There was a male predominance in both groups (Table 2). In the GFMF group, there were more smokers at the time of surgery and more patients received a combination of chemoradiotherapy preoperatively than radiotherapy alone. The post-operative complication rate was overall higher in the PMMF reconstructions group (Table 3). However, this was not statistically significant. Most of the complications occurred early. Six patients with PMMF reconstruction had developed clinical fistulae, four of which required surgical repair. In the GFMF group, five patients developed clinical fistulae and two required surgical repair. One of these patients developed a chronic fistula following a failed gracilis flap, which required a separate PMMF reconstruction. This had occurred before the introduction of the Cook-Swartz Doppler Flow Monitoring System (Cook Vascular, Inc. Vandergrift, Pennsylvania) to our unit, which we now routinely use to monitor buried head and neck free flaps in the immediate post-operative period.
Variable
PMMF
GFMF
Patient no. Gender Male Female Age (years) Mean Range Coexisting co-morbidities Smokers at time of surgery, (no) No. of CRT No. of RT Neck dissections Timing of C/RT to STL (months) Mean Range T, (No) 1 2 3 4 N, (No) 0 1 2 3 M, (No) 0 1
27
22
26 1
19 3
67.4 44e89 18 1 4 23 27
64.8 50e84 17 4 7 15 22
16.2 1e96
12.7 5e38
8 10 2 7
7 6 7 1
20 2 3 2
19 1 1 0
27 0
22 0
Abbreviations: PMMF, pectoralis major muscle flap; GFMF, gracilis free muscle flap; CRT, chemoradiotherapy; RT, radiotherapy.
Other than the formation of PCF, wound healing problems were the most common amongst the PMMF group. One patient died from an acute cerebrovascular event early in the post-operative period. In the GFMF group, one type-2 diabetic patient with a large supraglottic tumour developed wound dehiscence, which led to neopharyngeal perforation and a chronic fistula.
Discussion First described by Billroth, the formation of pharyngocutaneous fistula following laryngectomy is a common complication. It clinically presents as salivary leak and develops when there is a failure in the pharyngeal repair.15 Typically, this occurs just above the tracheostomy site at the weakest point of suture line.15 A number of causative factors have been described. Most authors would agree that the use of primary chemoradiation before surgery in the current organ preservation management of laryngeal cancers is the key causative factor.1,3,10 The prevention and management of fistulae are challenging. Pedicled pectoralis major muscle flap has been the
Comparison between free gracilis MF and pedicled PMF reconstructions Table 3 Post-operative complications following free gracilis and pedicled pectoralis major muscle flap reconstructions for total laryngectomy. Complications
PMMF No.
GFMF No.
Total no of complications Early complications (<30 days) Delayed complication (30 days) Clinical formation of pharyngocutaneous fistula Pharyngocutaneous fistula requiring surgery Haematoma Wound dehiscence Neopharynx perforation Poor wound healing Flap loss Mortality
12 9 3 6 (3a, 3b)
8 5 3 5 (4a, 1b)
4
2
4a 0 0 1a 0 1a
0 1b 1b 0 1a 0
Abbreviations: PCF, pharyngocutaneous fistula, PMMF, pectoralis major muscle flap, GFMF, gracilis free muscle flap. a Early complication occurred less than 30 days postoperatively. b Delayed complication occurred 30 days or more postoperatively.
21
team for flap harvest and the other team for laryngectomy and preparation of the recipient site. Despite radiotherapy, vessels are usually amenable for free tissue transfer. The aesthetic appearance of the flap inset is superior to the pectoralis muscle flap and the donor is site better also. We have found that increasing numbers of head and neck cancer patients are presenting early as a result of human papillomavirus infection and also with concurrent primary malignancies of this region. With improved medical care and increasing longevity of patients, it is important to consider the likelihood of future reconstructive problems in this patient group. Using a free gracilis as a primary option preserves a non-microsurgical option (PMMF) for future reconstruction should the disease recur or subsequent primary head and neck carcinomas develop. In addition, microsurgical salvage after a previous laryngectomy and pectoralis major flap is much more difficult than performing the microsurgery in the primary surgical setting, even after radiotherapy. Our experience shows that the free gracilis free flap provides a good alternative to the pedicled pectoralis major muscle flap as a robust option in the prophylaxis of pharyngocutaneous fistula following salvage laryngectomy.
Conflict of interest/funding workhorse reconstructive choice for this purpose. Some authors have reported a significant reduction in fistula formation (50%e0%) and reduced complications following the use of PMMF.16 Most of the benefits were observed in patients with co-morbidities, poor nutritional status and in large post-laryngectomy defects.8,17,18,19 However, Gil et al. had recently concluded that there was no significant difference in the incidence of fistula formation and local wound complications between patients who had PMMF and those who had primary laryngectomy defect closure following radiorecurrence of disease. Free flaps have been increasingly used as an alternative to PMMF.3,20 Fung et al. have recently found that RFFF and ALT flaps were effective in preventing major wound complications but did not reduce the overall fistula rate.9 The outcomes of free flap reconstructions to reinforce primary closures following salvage laryngectomy have not previously been compared to that of PMMF reconstructions. This study has shown that the gracilis flap had a comparative fistula rate to that of the pectoralis major flap, but with a lower donor site co-morbidity. In our experience, PMMF flap leaves a painful disfiguring scar over the chest and a visible bulge over the clavicle. This can impinge on the tracheostomy site and increase the risk of respiratory compromise, particularly in a cohort of patients who often have coexisting chest disease. It may distort the position of breasts in female patients and is commonly associated with wound complications. It is not usually possible to raise the pectoralis major muscle flap at the same time as the salvage laryngectomy. In our series, free gracilis muscle flap has produced good results. It is a long and thin muscle, which is of a good size, shape and volume to buttress the pharyngeal suture line. The flap was easily raised in a two-team approach with one
None.
Acknowledgement We would like to acknowledge Mr Animesh Patel for providing the photographs.
References 1. Qureshi SS, Chaturvedi P, Pai PS, et al. A prospective study of pharyngocutaneous fistulas following total laryngectomy. J Cancer Res Ther 2005;1:51e6. 2. Paydarfar JA, Birkmeyer NJ. Complications in head and neck surgery: a meta-analysis of postlaryngectomy pharyngocutaneous fistula. Arch Otolaryngol Head Neck Surg 2006;132: 67e72. 3. Gil Z, Gupta A, Kummer B, et al. The role of pectoralis major muscle flap in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 2009;135:1019e23. 4. McLean JN, Nicholas C, Duggal P, et al. Surgical management of pharyngocutaneous fistula after total laryngectomy. Ann Plast Surg 2012;68:442e5. 5. Grau C, Johansen LV, Hansen HS, et al. Salvage laryngectomy and pharyngocutaneous fistulae after primary radiotherapy for head and neck cancer: a national survey from DAHANCA. Head Neck 2003;25:711e6. 6. Ganly I, Patel S, Matsuo J, et al. Postoperative complications of salvage total laryngectomy. Cancer 2005;103:2073e81. 7. Hier M, Black MJ, Lafond G. Pharyngo-cutaneous fistulas after total laryngectomy: incidence, etiology and outcome analysis. J Otolaryngol 1993;22:164e6. 8. Smith TJ, Burrage KJ, Ganguly P, Kirby S, Drover C. Prevention of postlaryngectomy pharyngocutaneous fistula: the Memorial University experience. J Otolaryngol 2003;32:222e5.
22 9. Fung K, Teknos TN, Vandenberg CD, et al. Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 2007;29:425e30. 10. Bohannon IA, Carroll WR, Magnuson JS, Rosenthal EL. Closure of post-laryngectomy pharyngocutaneous fistulae. Head Neck Oncol 2011;26:29. 11. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73e81. 12. Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26:1018e23. 13. El-Marakby H. The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Canc Inst 2006;18:41e50. 14. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope 2007;117:781e4.
S.S. Jing et al. 15. Saki N, Nikakhlagh S, Kazemi M. Pharyngocutaneous fistula after laryngectomy: incidence, predisposing factors, and outcome. Arch Iran Med 2008;11:314e7. 16. Patel UA, Keni SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 2009;141:190e5. 17. Righini C, Lequeux T, Cuisnier O, Morel N, Reyt E. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005;262:357e61. 18. Castelli ML, Pecorari G, Succo G, Bena A, Andreis M, Sartoris A. Pectoralis major myocutaneous flap: analysis of complications in difficult patients. Eur Arch Otorhinolaryngol 2001;258:542e5. 19. Mebeed AH, Hussein HA, Saber TKh, Zohairy MA, Lotayef M. Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect. J Egypt Natl Canc Inst 2009;21:23e32. 20. Del Frari B, Schoeller T, Wechselberger G. Reconstruction of large head and neck deformities: experience with free gracilis muscle and myocutaneous flaps. Microsurgery 2010;30:192e8.
A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy* Shan Shan Jing*, Trevor O’Neill, Jonothan J. Clibbon Department of Plastic Surgery, Norfolk and Norwich University Hospital, Norwich, UK Received 5 June 2013; accepted 14 August 2013
KEYWORDS Fistula; Pectoralis major; Laryngectomy; Radiorecurrent; Gracilis
Summary Introduction: Muscle flaps are often used in the prevention and treatment of pharyngocutaneous fistula following total salvage laryngectomy in the setting of chemo-radiated neck for laryngeal carcinomas. We report our experience with the gracilis free muscle flap compared to the pedicled pectoralis major for the prophylaxis of fistula formation. Methods: Forty-nine patients with radio-recurrent laryngeal carcinoma over ten years who underwent salvage laryngectomy and either immediate free gracilis (22 patients) or pedicled pectoralis major muscle flap (27 patients) reconstruction were reviewed. Results: There were 12 complications in pectoralis major flap group and eight in gracilis flap group. Most of these occurred early in the post-operative period. These were related to poor wound healing with the pectoralis major flap reconstructions. Fistulation rates were similar in the two groups (Pectoralis major: 6/27, gracilis: 5/22). Conclusions: In our experience, the gracilis free muscle flap is a good reconstructive option in the prevention of pharyngocutaneous fistula formation following salvage laryngectomies. It is at least equivalent to a pectoralis muscle flap in the prevention of fistulae, but we prefer the gracilis for many reasons, including ease of harvest and preservation of the pectoralis major flap for future reconstructions. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Previous presentations: This original paper has been previously presented at Doctors Update Meeting in Val D’Isere, 30th January 2012 and at the 5th European Head and Neck Society Meeting in Poznan, 21st April 2012. * Corresponding author. E-mail address: [email protected] (S.S. Jing).
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.018
18
S.S. Jing et al.
Introduction The development of a pharyngocutaneous fistula (PCF) remains the most common and challenging complication following total laryngectomies. It leads to delays of the adjuvant treatments and prolonged hospitalization. The incidence of fistula reported in the literature is variable, ranging from 5% to 65%.1,2 Causative factors associated with its formation have been extensively studied. These include the age and sex of the patients, medical comorbidities, patients’ smoking status, tumour site and stage, preoperative tracheostomy, concurrent neck dissections, surgical closure techniques, and the peri-operative haemoglobin level.1,2 However, the significance of these factors remains controversial. In the recent years, the treatment of laryngeal cancers has moved away from primary laryngectomy towards organ preservation, with the use of initial chemoradiation followed by salvage laryngectomy for subsequent disease recurrence.3 This change in practice has led to a significant increase in the incidence and severity of fistula development.2e4 PCF following radiotherapy and laryngectomy occurs 2.6 times more frequently than compared to primary laryngectomy alone.5 The additional use of chemotherapy is associated with a further 2 fold increase in the fistula rate.3,6 The timing of chemoradiotherapy to surgery and the dosage adds further implications.3,7 As a result, some authors have advocated for flap reconstruction at the time of laryngectomy in an effort to reinforce the primary pharyngeal suture line with vascularized tissue to prevent fistula formation.3,8,9 Repair of an established fistula is associated with more complications and poorer outcomes.10 First popularized by Ariyan (1979), the pedicled pectoralis major muscle flap (PMMF) has been the workhorse flap for this indication.11 It is robust and locally available, but can carry a reasonably high complication rate (36.1%).4,12,13
Microvascular free flaps such as the radial forearm flaps and anterolateral thigh flaps have also used.9,14 The outcome of the pedicled and free muscle flap has not been formally reported. Gracilis free muscle flap (GFMF) is not widely used in head and neck reconstructions, but it has the potential to give excellent results. It is a vascularized tissue with a reliable pedicle anatomy, good plasticity and low donor site morbidities. Table 1 illustrates its advantages. This study reports our experience of using the GFMF reconstruction compared to the PMMF in buttressing the pharyngeal suture line to prevent fistula formation at the time of salvage laryngectomy for radiorecurrent laryngeal carcinomas.
Patients and methods Between May 1999 and March 2011, 49 salvage total laryngectomies without concurrent pharyngectomy and immediate GFMF or PMMF flap reconstructions for radiorecurrent laryngeal squamous cell carcinomas following failed primary chemoradiotherapy at a single tertiary unit were reviewed. The reconstructions were performed by experienced surgeons using a similar laryngectomy closure technique.
Surgical technique Pedicled pectoralis major muscle flap reconstruction With the patient lying supine, the pedicled pectoralis major muscle flap was raised through an oblique incision on the anterior chest wall in a defensive approach preserving the detopectoral flap. The skin was raised above the pectoralis major muscle fascia. The muscle was then released from its lateral and inferior attachments and dissected off the chest wall from lateral to medially in the submuscular plane until it was islanded around a pedicle which coursed on its under
Table 1 Advantages and disadvantages of pedicled pectoralis major muscle flap compared to the free gracilis muscle flap for the reinforcement of primary laryngectomy closure following salvage total laryngectomy. Features
Pectoralis major muscle flap
Gracilis free muscle flap
Advantages
Reliable Robust
Reliable Good volume and size for buttressing laryngectomy closure Can be harvested with skin paddle Lower donor site morbidity Better aesthetic outcome than pedicled pectoralis major muscle flap Allows the flap to be raised simultaneously to the laryngectomy
Good volume for buttressing laryngectomy closure Can be harvested with skin paddle
Disadvantages
Potential respiratory compromise Poor aesthetic outcome e scar on chest, muscle bulge over clavicle, potential distortion of breast in female patients, split thickness skin graft may be required. Reduced neck movement Can not be raised simultaneously to laryngectomy Limited arc or rotation and transposition
Microsurgery required Postoperative monitoring is difficult as it is a buried flap.
Comparison between free gracilis MF and pedicled PMF reconstructions
19
Figure 1 This illustrates the pedicled pectoralis major muscle flap being raised from the anterior chest wall in the sub-muscular plane with the pedicled running on its undersurface.
surface (Figure 1). The pedicled muscle flap was transposed under the skin bridge and pivoted over the clavicle (Figure 2). It was laid over the laryngectomy closure site and secured to the base of the tongue superiorly, sternocleidomastoid muscles laterally and to the apex of the tracheostomy site inferiorly (Figure 3).
Figure 3 The pedicled pectoralis major muscle flap is positioned over the primary closure of the defect following a salvage total laryngectomy.
Free gracilis muscle flap reconstruction With the patient was positioned supine, an axial incision from the pubic ramus to the mid thigh was made. The muscle was harvested in a distal to proximal and posterior to anterior approach from the adductor compartment. Distal perforators to the muscle were divided and the pedicle was identified. The gracilis muscle was released from its tendinous origin (Figure 4). Suitable recipient vessels were identified in the neck for microvascular anastomosis (Figure 5). A venous coupler was used for the veins where possible. The muscle was secured in the same
manner as the pedicled pectoralis major flap over the closure of the laryngectomy defect. Post-operatively, patients were commenced on nasogastric tube feed until a routine contrast swallow test was performed on day 10 to exclude a radiological leak. If no leak was identified, the patients were then commenced on oral intakes; otherwise, patients remained on the enteral feed until they had passed subsequent swallow tests. The mean follow-up was 24 months. Complications that occurred within 30 days following surgery were recorded as early and thereafter were recorded as delayed. Statistical analysis using Chi square test of association and Fisher’s exact 2-tailed probability test were performed.
Figure 2 This illustration shows the pedicled pectoralis major flap under a cutaneous tunnel prior to transfer and flap inset.
Figure 4 This illustrates the free gracilis muscle flap being raised through an open approach with the pedicle still attached simultaneous to the total laryngectomy.
20
S.S. Jing et al. Table 2 Demographics of the 49 patients who had pedicled pectoralis major muscle and free gracilis flap reconstruction following salvage laryngectomy for radiorecurrent disease and laryngeal cancer stage (TNM staging system).
Figure 5 The free gracilis muscle flap is anastamosed to the facial artery and vein before it is positioned over the primary closure of the total laryngectomy defect.
Results Over a period of 11 years and ten months, 27 patients underwent PMMF flap reconstructions and 22 had GFMF flap reconstructions. There was a male predominance in both groups (Table 2). In the GFMF group, there were more smokers at the time of surgery and more patients received a combination of chemoradiotherapy preoperatively than radiotherapy alone. The post-operative complication rate was overall higher in the PMMF reconstructions group (Table 3). However, this was not statistically significant. Most of the complications occurred early. Six patients with PMMF reconstruction had developed clinical fistulae, four of which required surgical repair. In the GFMF group, five patients developed clinical fistulae and two required surgical repair. One of these patients developed a chronic fistula following a failed gracilis flap, which required a separate PMMF reconstruction. This had occurred before the introduction of the Cook-Swartz Doppler Flow Monitoring System (Cook Vascular, Inc. Vandergrift, Pennsylvania) to our unit, which we now routinely use to monitor buried head and neck free flaps in the immediate post-operative period.
Variable
PMMF
GFMF
Patient no. Gender Male Female Age (years) Mean Range Coexisting co-morbidities Smokers at time of surgery, (no) No. of CRT No. of RT Neck dissections Timing of C/RT to STL (months) Mean Range T, (No) 1 2 3 4 N, (No) 0 1 2 3 M, (No) 0 1
27
22
26 1
19 3
67.4 44e89 18 1 4 23 27
64.8 50e84 17 4 7 15 22
16.2 1e96
12.7 5e38
8 10 2 7
7 6 7 1
20 2 3 2
19 1 1 0
27 0
22 0
Abbreviations: PMMF, pectoralis major muscle flap; GFMF, gracilis free muscle flap; CRT, chemoradiotherapy; RT, radiotherapy.
Other than the formation of PCF, wound healing problems were the most common amongst the PMMF group. One patient died from an acute cerebrovascular event early in the post-operative period. In the GFMF group, one type-2 diabetic patient with a large supraglottic tumour developed wound dehiscence, which led to neopharyngeal perforation and a chronic fistula.
Discussion First described by Billroth, the formation of pharyngocutaneous fistula following laryngectomy is a common complication. It clinically presents as salivary leak and develops when there is a failure in the pharyngeal repair.15 Typically, this occurs just above the tracheostomy site at the weakest point of suture line.15 A number of causative factors have been described. Most authors would agree that the use of primary chemoradiation before surgery in the current organ preservation management of laryngeal cancers is the key causative factor.1,3,10 The prevention and management of fistulae are challenging. Pedicled pectoralis major muscle flap has been the
Comparison between free gracilis MF and pedicled PMF reconstructions Table 3 Post-operative complications following free gracilis and pedicled pectoralis major muscle flap reconstructions for total laryngectomy. Complications
PMMF No.
GFMF No.
Total no of complications Early complications (<30 days) Delayed complication (30 days) Clinical formation of pharyngocutaneous fistula Pharyngocutaneous fistula requiring surgery Haematoma Wound dehiscence Neopharynx perforation Poor wound healing Flap loss Mortality
12 9 3 6 (3a, 3b)
8 5 3 5 (4a, 1b)
4
2
4a 0 0 1a 0 1a
0 1b 1b 0 1a 0
Abbreviations: PCF, pharyngocutaneous fistula, PMMF, pectoralis major muscle flap, GFMF, gracilis free muscle flap. a Early complication occurred less than 30 days postoperatively. b Delayed complication occurred 30 days or more postoperatively.
21
team for flap harvest and the other team for laryngectomy and preparation of the recipient site. Despite radiotherapy, vessels are usually amenable for free tissue transfer. The aesthetic appearance of the flap inset is superior to the pectoralis muscle flap and the donor is site better also. We have found that increasing numbers of head and neck cancer patients are presenting early as a result of human papillomavirus infection and also with concurrent primary malignancies of this region. With improved medical care and increasing longevity of patients, it is important to consider the likelihood of future reconstructive problems in this patient group. Using a free gracilis as a primary option preserves a non-microsurgical option (PMMF) for future reconstruction should the disease recur or subsequent primary head and neck carcinomas develop. In addition, microsurgical salvage after a previous laryngectomy and pectoralis major flap is much more difficult than performing the microsurgery in the primary surgical setting, even after radiotherapy. Our experience shows that the free gracilis free flap provides a good alternative to the pedicled pectoralis major muscle flap as a robust option in the prophylaxis of pharyngocutaneous fistula following salvage laryngectomy.
Conflict of interest/funding workhorse reconstructive choice for this purpose. Some authors have reported a significant reduction in fistula formation (50%e0%) and reduced complications following the use of PMMF.16 Most of the benefits were observed in patients with co-morbidities, poor nutritional status and in large post-laryngectomy defects.8,17,18,19 However, Gil et al. had recently concluded that there was no significant difference in the incidence of fistula formation and local wound complications between patients who had PMMF and those who had primary laryngectomy defect closure following radiorecurrence of disease. Free flaps have been increasingly used as an alternative to PMMF.3,20 Fung et al. have recently found that RFFF and ALT flaps were effective in preventing major wound complications but did not reduce the overall fistula rate.9 The outcomes of free flap reconstructions to reinforce primary closures following salvage laryngectomy have not previously been compared to that of PMMF reconstructions. This study has shown that the gracilis flap had a comparative fistula rate to that of the pectoralis major flap, but with a lower donor site co-morbidity. In our experience, PMMF flap leaves a painful disfiguring scar over the chest and a visible bulge over the clavicle. This can impinge on the tracheostomy site and increase the risk of respiratory compromise, particularly in a cohort of patients who often have coexisting chest disease. It may distort the position of breasts in female patients and is commonly associated with wound complications. It is not usually possible to raise the pectoralis major muscle flap at the same time as the salvage laryngectomy. In our series, free gracilis muscle flap has produced good results. It is a long and thin muscle, which is of a good size, shape and volume to buttress the pharyngeal suture line. The flap was easily raised in a two-team approach with one
None.
Acknowledgement We would like to acknowledge Mr Animesh Patel for providing the photographs.
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22 9. Fung K, Teknos TN, Vandenberg CD, et al. Prevention of wound complications following salvage laryngectomy using free vascularized tissue. Head Neck 2007;29:425e30. 10. Bohannon IA, Carroll WR, Magnuson JS, Rosenthal EL. Closure of post-laryngectomy pharyngocutaneous fistulae. Head Neck Oncol 2011;26:29. 11. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73e81. 12. Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26:1018e23. 13. El-Marakby H. The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Canc Inst 2006;18:41e50. 14. Withrow KP, Rosenthal EL, Gourin CG, et al. Free tissue transfer to manage salvage laryngectomy defects after organ preservation failure. Laryngoscope 2007;117:781e4.
S.S. Jing et al. 15. Saki N, Nikakhlagh S, Kazemi M. Pharyngocutaneous fistula after laryngectomy: incidence, predisposing factors, and outcome. Arch Iran Med 2008;11:314e7. 16. Patel UA, Keni SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 2009;141:190e5. 17. Righini C, Lequeux T, Cuisnier O, Morel N, Reyt E. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005;262:357e61. 18. Castelli ML, Pecorari G, Succo G, Bena A, Andreis M, Sartoris A. Pectoralis major myocutaneous flap: analysis of complications in difficult patients. Eur Arch Otorhinolaryngol 2001;258:542e5. 19. Mebeed AH, Hussein HA, Saber TKh, Zohairy MA, Lotayef M. Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect. J Egypt Natl Canc Inst 2009;21:23e32. 20. Del Frari B, Schoeller T, Wechselberger G. Reconstruction of large head and neck deformities: experience with free gracilis muscle and myocutaneous flaps. Microsurgery 2010;30:192e8.