Use of The Pectoralis Major Musculocutaneous Flap for One-Stage Cervical, Esophageal, and Pharyngeal Reconstruction
R. F. RYAN
Reconstruction of the cervical esophagus has challenged surgeons for many years (1). Until 15 years ago, it was not unusual for patients needing esophageal replacement to undergo 20 or 30 operations. The two major developments in solving the problem of cervical esophageal replacement were the deltopectoral flap (2) and the development of free microvascular flaps of jejunum (3). The disadvantage of the Bakamjian flap was that it required two or three stages if it required a delay. The jejunal flap required an abdominal procedure and the risk of microvascular failure.
The pectoralis major musculocutaneous flap can be used to replace the cervical esophagus and lower pharynx.
The following is a description of the procedure as performed on the first patient: Preoperative examination of the cervical esophagus in this female patient showed only a small linear lesion about 1 cm wide and 2.5 cm long. The patient had previously undergone extensive radiation over the neck, a left radical neck resection, a right modified neck resection, and a laryngectomy. The oncologic surgeon planned to open the old midline T incision from the laryngectomy radical neck incision and resect the anterior portion of the esophagus. Unfortunately, the tumor extended submucosally and required resection of the entire esophagus from the level of the tracheostomy up to the posterior pharyngeal wall and resection of the gullet after a previous glossectomy and laryngectomy.
I was aware of previous failures in which musculocutaneous flaps had been sutured in a straight line along the borders of the skin to make a skin-lined tube. I also was aware that a hollow tube can be made by a narrow pedicle if it is sutured in a spiral manner, as is done with the cardboard core for a roll of toilet tissue. Moreover, muscular contractions would tend to seal a spiral tube of skin rather than distract the edges and form fistulas.
A long pectoralis major muscle cutaneous flap was therefore elevated (7), as shown in Figures 218.1, 218.2, 218.3, 218.4. Because this was the first time I had done such a procedure, the pedicle was first tacked to one side. This would not work, so it was sutured to the other side of the oral cavity and then sutured in a spiral fashion. Because the new esophagus was of a much greater diameter than the remaining esophagus, the distal esophagus was split, as when anastomosing vessels of different diameters (Figs. 218.5 and 218.6).