Prefabrication techniques in cervical pharyngo-oesophageal reconstruction

British

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(1973),

26, ZI+-zzz

PREFABRICATION TECHNIQUES IN CERVICAL PHARYNGO-OESOPHAGEAL RECONSTRUCTION By V. Y. BAKAMJIAN, M.D., and L. A. HOLBROOK, F.R.C.S.] Roswell Park Memorial Institute, Buffalo, New York THE

idea of ectopically prefabricating an anatomical structure from a skin flap, before transfer to its final site, is not new; the principle has been applied to nose reconstruction where bone, cartilage, or mucosa and cartilage have been introduced beneath a skin Thus, Lexner in 1914 inserted two flap in combination with a delaying procedure. small pieces of tibia1 bone under a forehead flap, and Fritz Koenig followed soon after with the use of a cruciate piece of sternal bone and cartilage to pre-shape a nose in the skin of the forearm (Denecke and Meyer, 1967). More recently Converse (1959) described using composite grafts of septal mucosa and cartilage under a forehead flap with similar The following four brief case presentations illustrate the evolution of the purpose. senior author’s prefabrication approach to some mandatory instances of secondary pharyngo-oesophageal reconstruction, the intent being to ease some of the difficulties encountered in such repairs. The varying flaps used as basic material reflect the development of techniques at this unit in other more conventional staged procedures for head and neck reconstructions. Case I. A 4S-year-old man had undergone total pharyngo-laryngectomy and right radical neck node dissection for an extensive supraglottic laryngeal cancer in August 1962. The resecting surgeon, not seeing fit to attempt immediate reconstruction of the pharynx, had applied the anterior neck skin directly over the prevertebral muscles, leaving a large oropharyngocutaneous stoma at the base of the tongue and an oesophagostome just behind the site of tracheostome. He then referred the patient for secondary reconstruction. At this time when we had not yet discovered the special merits of the deltopectoral flap (Bakamjian, 1965; Bakamjian et al., 1967), we were still frequently using cervical flaps as the most direct tissue source for pharyngeal and intra-oral repairs (Bakamjian and Littlewood, 1964). However, the neck skin was not suitable in the case on hand because of excessive hairiness, and, furthermore, inverting it for formation of the new gullet would additionally necessitate skin from elsewhere to cover the front of the neck. It appeared logical, therefore, to prefabricate a hollow tube from the much less hairy skin available on the anterior chest wall, and subsequently to transfer it to the neck by means of a neck pedicle for positioning between the existing stoma1 openings on the front of the neck. It was thought also that Owens’ (1955) compound neck pedicle could be used as the carrier, considering the margin of safety conferred on it by inclusion of the sternomastoid muscle as an additional source of blood supply (Bakamjian, 1963). A rectangle of upper anterior chest wall skin was marked, extending horizontally and somewhat obliquely downward from the left mid-clavicular line to just beyond the right border of the sternum. Both ends of the rectangle and the right halves of the upper and lower borders were incised, and the whole area was undermined. The free right half was then tubed, its skin surface inward, and passed under the left half, forming thus a skin-lined tube covered by a further layer of skin. The terminal circumference of the buried tube was sutured to the lips of the left end incision of the rectangle, and the denuded right half was covered with splitthickness skin grafts (Fig. I, A). In a further delaying procedure a few weeks later, the left half of the original rectangle was incised on 3 sides, leaving its superior border intact as its attachment to the proposed carrying neck flap. At the next stage the entire prefabricated structure was raised on its cervical pedicle, but 1Present address: Burns and Plastic Unit, Whiston Hospital, Prescot, England. 214

FIG. I. A, Shows Case I after total laryngo-pharyngectomy and right radical neck node dissection, with an oropharyngostome, oesophagostome and tracheostome, and a skin tunnel on the anterior chest wall prefabricated for secondary pharyngooesophageal reconstruction. B, Shows the prefabricated skin tube transferred to the neck. C, Shows guIlet continuity restored by anastomosis of the skin tube to the oropharyngostome above and the oesophagostome below. FIG. 2. Shows Case 2 after total laryngo-pharyngectomyandleft radical neck dissection, which included removal of a portion from the left base of the tongue, the left half of the soft palate, and left lateral naso.yngeal wall. Note that a skin graft has been applied over the denu tded prev ,ertebral muscles without attempting immediate reconstruction of the pharynx.

FIG. 2

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without the additional safeguard of including the sternomastoid muscle as originally intended, and it was moved to the proper position on the neck (Fig. I, B). The repair was completed after another few weeks, establishing continuity between the skin tube and the oropharyngeal and the oesophageal stomata (Fig. I, c). A left radical neck node dissection was performed at

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the same time for metastases that meanwhile had become evident on that side. Normal swallowing followed the reconstruction and functioned well until the patient died from metastatic disease in the mediastinum and lungs 5 years later.

FIG. 4. A, Shows monobloc specimen removed from Case 3, including anterior mandibular alveolectomy, total glossectomy, supraglottic laryngectomy, and simultaneous bilateral radical neck node dissection. B, Result after a secondary laryngo-pharyngectomy for recurrent cancer and conversion of the oropharynx into a closed blind pouch to avoid the inconveniences of a salivary fistula. C, Skin tunnel prefabricated from the horizontal limb of an L-shaped, paramedian, dorsal flap. D, The vertical carrier limb of the flap tubed in readiness for the transfer. Unfortunately the latter was never done because of recurrent cancer in the neck which failed to respond to irradiation.

Case 2. A jo-year-old man had undergone left radical neck node dissection and total pharyngo-laryngectomy in January 1962, including a large portion from the left base of the tongue, the left half of the soft palate and the lateral oro-naso-pharyngeal wall. As in Case I, no immediate reconstruction had been attempted, placing only a split-thickness skin graft over the denuded prevertebral muscles (Fig. 2). A suspicion of inadequacy of the cancer removal superolaterally in the nasopharynx and at the base of the skull had been confirmed by histological sections, and post-operative irradiation had been given. ApproximateIy a year after, enlargement

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of nodes on the contra-lateral side had necessitated a right radical neck node dissection, but no cancer had been disclosed in the nodes. Thereafter, the patient remained free of disease and he was referred for secondary reconstruction of the pharynx in September 1963. Considering that the potential neck donor areas for flaps had been compromised by the foregoing two operations and irradiation, a prefabrication technique was chosen. A vertical rectangle of skin was marked somewhat obliquely on the back of the left shoulder girdle and chest, attached by the upper half of its medial border to a horizontally oriented carrier pedicle based at the left nape of the neck (Fig. 3, A). Thus the total flap area marked was again Lshaped. The upper border of the rectangle, and 3 sides of its lower half were incised as marked by the solid lines in Figure 3, A and the entire area of the rectangle was undermined. The free lower half was tubed, skin surface inward, and folded under the upper half, thus forming a

FIG. 5. Shows Case 4 after total laryngo-pharyngectomy with right neck dissection and excision of the base of the tongue, and failure of the primary pharyngooesophageal reconstruction with a right deltopectoral flap due to a necrotising infection.

structure similar to that used in Case I (Fig. 3, B). A second delaying procedure consisted of raising and tubing the carrier pedicle, and a third delay simply of incising the left end of the prefabricated structure. Transfer to the neck was achieved in a fourth stage (Fig. 3, c), and the anastomoses to oropharynx and oesophagus were established with a fifth stage when the carrier pedicle was also divided (Fig. 3, D and E). Satisfactory swallowing followed, and the patient was alive and well when last reviewed in June 1972, IO years after the resection. Case 3. A 57-year-old man was admitted in October 1963 with bilateral large neck The initial treatment was surgical and metastases from a far advanced cancer of the tongue. consisted of a monobloc resection which included anterior mandibular alveolectomy, total glossectomy, supraglottic laryngectomy, and bilateral radical neck node dissection (Fig. 4, A), and repair of the floor of the mouth with cervical skin flaps. One month later it became necessary to remove persistent cancer in the region with a laryngo-pharyngectomy. Reconstruction was not attempted, and the oropharynx was closed into a blind pouch as suggested by Harrold (1957) to avoid the considerable inconveniences of a large salivary fistula while awaiting completion of a secondary pharyngeal reconstruction (Fig. 4, B). A further month

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later, reconstruction with a prefabrication technique similar to that used in Case 2 was commenced. Feeling, however, that in this instance a longer pedicle was desirable to give greater mobility to the prefabricated structure, the pharyngeal skin tube was fashioned from a rectangle transversely beneath the angle of the left scapula, the other limb of the L-shaped flap lying vertically parallel with the spine (Fig. 4, c). This limb was later raised and tubed to form the superiorly based carrying pedicle (Fig. 4, D). Unfortunately, before final transfer of the pre-

FIG.

6.

A, Shows the deltoid portion of an elongated deltopectoral flap on the left shoulder of the pharynx in Case 4. 3, The proximal pectoral portion of C, The deltoid segment tubed, skin surface inward. D, The tubed segment buried under the proximal half of the flap.

elevated for prefabrication the flap seen undermined.

structure, a recurrence of cancer prevented completion of the reconstruction, and in spite of radiation therapy, the disease progressed causing the patient’s demise in January 1965. jfabricated

Case 4. A 56-year-old man with supraglottic squamous cell cancer which had extended to the base of the tongue and posterior pharyngeal wall was treated with pharyngo-laryngectomy and right neck node dissection in January 1971. This was immediately followed with the first stage of a cervical pharyngo-oesophageal reconstruction with a primary deltopectoral flap (Bakamjian, 1965), but unfortunately a necrotising infection caused loss of the deltopectoral gap and the overlying cover of neck skin. The resultant denuded area of prevertebrai muscles

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was subsequently covered with Thiersch grafts, leaving an oropharyngostome above and an oesophagostome below (Fig. 5), and secondary reconstruction with prefabrication of the required structure was commenced in February 1971. An elongated left deltopectoral flap was used, its tip extending straight around the shoulder

FIG. 7. A, Shows the prefabricated structure in Case 4 freed. B, The prefabricated structure elevated. C, The prefabricated structure transposed to the neck, and the free end of the skin tunnel anastomosed to the oesophageal stump. D, Final result after anastomosis of skin tube to the oropharyngeal stoma and division of the base of the pedicle. E, Profile view, showing skin graft in the distal portion of the deltopectoral donor wound.

to the lateral edge of the scapula. The deltoid portion of the flap was outlined and raised (Fig. 6, A) and the proximal pectoral portion was undermined without incising its margin (Fig. 6, B). The deltoid half was then tubed, skin surface inward (Fig. 6, c), and it was folded under the pectoral portion (Fig. 6, D). This manoeuvre was accomplished with 2 silk sutures on the flap end, passed under and through the base of the flap to be tied over small sections of rubber tubing to maintain the structure in proper position. The denuded deltoid donor area was covered with split-thickness skin graft.

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Nine days later the remaining margins of the pectoral portion of the flap were delayed, and after a further 19 days the prefabricated structure was raised and inset at its final site on the neck, anastomosing the free end of the buried skin tube to the oesophageal stump (Fig. 7, A-C). The remaining upper neck opening was closed when the base of the flap was divided a few weeks later. The completed repair was functioning well, with no leaks, 3 months after the first stage was undertaken. The patient has since had a further metastasis removed from the base of the left neck and received irradiation to the mediastinum. To date, in July 1972, he remains alive and well, although we suspect he has residual cancer in the lymph nodes of the mediastinum. DISCUSSION

These 4 cases illustrate the evolution of pharyngo-oesophageal reconstruction at this unit. The initial attraction of the distant prefabrication concept lay in the ample quantity of skin made available for reconstruction, in comparison with local neck flaps. Also, when compared with more conventional skin transfer by tubed pedicle flaps it offered a relatively small number of stages. However, with the advent of the deltopectoral flap technique it was largely superseded, because a safe, simple, two-stage procedure with ample quantity of skin was then available for the routine reconstruction. Nonetheless, in the exceptional case, as described above, the concept is still valid and here the deltopectoral flap greatly enhances the ease and safety of the procedure. Where the investing neck skin must be replaced, in addition to the pharyngeal wall, the total quantity of required tissue can be obtained by simple elongation of the one flap. This is a safe procedure if a preliminary delay is used in the distal portion, and this delay presents the opportunity to prefabricate the skin tube, as described. Whereas in the previous cases the carrying pedicle met the main flap at a right angle, in this technique the main vasculature follows a straight course from the base of the pedicle throughout the flap, impaired only by the fold created in turning the tubed portion back beneath the investing layer. Adequately large vessels running in a convenient direction from the perforating branches of the internal mammary artery, appear to be a constant finding. Finally, for a historical note that was recently brought to our attention by McGregor (1970), we may add that Aymard’s early use of a tubed medially based deltopectoral pedicle, “the subject of a rather acrimonious correspondence in The Lancet between Gillies and Aymard concerning priority in the use of the tubed pedicle”, was, interestingly enough, for the purpose of transferring a prefabricated nasal structure from the shoulder to its correct position on the face. He “introduced a piece of cartilage under the skin of the shoulder-one piece about 24 inches long to form the main support and two lateral pieces at right angles and underneath the same . . .“, and 5 weeks later he performed the second stage which “consisted in separating and undercutting the pedicle . . . and sewing it together in tubed fashion” (Aymard, 1917, quoted by Webster, 1959). He also lined the tip of the flap, under the cartilage graft, with an epithelial graft introduced upon rubber to form the necessary lining of the nose. REFERENCES AYMARD,

J. L. (1917).

Lancet, 2, 888-891.

Nasal reconstruction.

With a note on nature’s plastic surgery.

BAKAMJIAN,V. Y. (1963). A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plastic and Reconstructive Surgery, 36, 173-184. Cervical skin flaps for intra-oral and BAKAMJIAN, V. Y. and LITTLEWOOD,M. (1964). pharyngeal repair following cancer surgery. British Journal of Plastic Surgery, 17, 191-210. BAKAMJIAN,V. Y. (1965). A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plastic and Reconstructive Surgery, 36, 173-184.

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BAKAMJIAN,V. Y., GULF, N. K. and BALES,H. W. (1967). Versatility of the deltopectoral flap in reconstructions following head and neck cancer surgery, in “Transactions of the Fourth International Congress of Plastic and Reconstructive Surgery”, pp. 808-815. Amsterdam: Excerpta Medica International Congress Services No. 174. CONVERSE?J. M. (1959). Use of composite grafts in conjunction with a forehead flap. Surgacal Clinics of North America, 39, 358-360. DENECKE,H. J. and MEYER,R. (1967). “Plastic Surgery of the Head and Neck”, Volume I, p. 403. New York, Springer-Verlag. HARROLD,C. C., Jr. (1957). The artificial pharyngeal pouch: Another alternative in reconstruction after laryngectomy. Cancer, IO, 928-932. MCGREGOR,I. A. and JACKSON,I. T. (1970). The extended role of the deltopectoral flap. British Journal of Plastic Surgery, 23, 173-185. OWEN, N. (1955). Compound neck pedicle designed for the repair of massive facial defects; formation, development and application. Plastic andReconstructive Surgqj? x5,369-389. WEBSTER,J. I’. (1959). The early history of the tubed pedicle flap. Surgtcal Clinics of North America, 39, 261-275.