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Reconstruction of the Posterior Pharyngeal Wall with a Deltopectoralis Flap in One-Step Surgical Intervention with Larynx Preservation

Soares, João Marcos A. Ph.D.; Santos, Marco Homero S. M.D.; Sousa, Alexandre A. M.D.; Moraes, Gustavo M. M.D.; Salles, José Maria P. M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 143e-144e
doi: 10.1097/PRS.0b013e3181e605fc
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Sir:

In the surgical treatment of tumors that are restricted to the posterior pharyngeal wall without signs of laryngeal invasion, pharyngeal reconstruction with larynx preservation is a challenge. The ideal technique among the various options for this type of reconstruction is one that maintains the organ's function as close to normal as possible, with low complication rates. We present two cases of surgical resection of the posterior pharyngeal wall with preservation of the larynx using a fasciocutaneous deltopectoralis flap for reconstruction in a one-step surgical intervention.

Two patients had posterior pharyngeal wall tumors, staged as T2N0, without extension to the larynx. Resection of the posterior wall of the pharynx was performed using lateral pharyngotomy associated with neck dissection at levels II to IV bilaterally. Laryngeal nerves and blood vessels were separated individually and preserved (Fig. 1). The tumor was then removed with a secure margin. A deltopectoralis flap was created and then sutured to the posterior wall of the pharynx in an attempt to reconstitute pharyngeal continuity. After suturing the distal part of the flap to the remaining pharyngeal mucosa, the proximal two-thirds of the flap epidermis was removed and grafted under the remains of the cervical wound (Figs. 2 and 3). This allowed for primary closure of the surgical wound.

Fig. 1.
Fig. 1.:
Repair of the laryngeal pedicle with a Penrose drain and opening of the pharynx through a lateral pharyngotomy and division of the suprahyoid muscles.
Fig. 2.
Fig. 2.:
The deltopectoralis flap attached to the posterior pharyngeal wall.
Fig. 3.
Fig. 3.:
The epidermis of the deltopectoralis scrap already removed with the creation of the covered area, which will remain under the cervical skin flap following suture.

The first patient presented a pharyngeal fistula and epidermolysis of the flap and was subjected to surgical reintervention for primary closure of the fistula. He recovered full oral deglutition function by day 45 after surgery. However, the patient died 30 months later because of cervical recurrence. The second patient presented microaspiration of fluids without major symptoms, allowing oral deglutition. Currently, after 50 months of follow-up, the patient is disease-free and demonstrates preserved larynx function, without microaspiration.

The reconstructive techniques described include cervical fascia flaps, fasciocutaneous flaps, muscle and cutaneous flaps, and free vascularized grafts. Cervical fascia flaps are thin and elastic, but are limited to patients who will be subjected to unilateral neck dissection.1 Pectoralis major flaps allow for reconstruction in a single surgical intervention. However, the volume and thickness of this flap may make reconstruction inadequate.2 Reconstructions that use free vascularized grafts have good results3; however, it requires a trained team that is not available in all head and neck surgical services. The deltopectoralis fasciocutaneous flap, as conceived by Bakamjian and Littlewood,4 is a thin, malleable, and easily manipulated material, and permits surface reconstruction in one surgical intervention. The removal of epidermis after suturing the flap on the pharyngeal posterior wall creates an uncovered area that may be placed under the cervical skin flap, and this eliminates the need for a second surgical intervention.

We believe that the partially deepithelialized deltopectoralis flap is a viable alternative for the reconstruction of pharyngeal defects. This can be performed in a single surgical intervention period following the resection of posterior pharyngeal wall tumors with laryngeal preservation.

João Marcos A. Soares, Ph.D.

Hospital das Clínicas

Universidade Federal de Minas Gerais

Belo Horizonte, Brazil

Federal University of São João del-Rei

Divinópolis, Brazil

Marco Homero S. Santos, M.D.

Alexandre A. Sousa, M.D.

Gustavo M. Moraes, M.D.

José Maria P. Salles, M.D.

Hospital das Clínicas

Universidade Federal de Minas Gerais

Belo Horizonte, Brazil

DISCLOSURE

The authors have no financial interest in this article or in any of the techniques described in this article.

REFERENCES

1.Ethanić D, Milicić D. The use of cervical fascia for hypopharyngeal reconstruction with laryngeal preservation. Eur Arch Otorhinolaryngol. 2003;260:207–210.
2.Julieron M, Kolb F, Schwaab G, et al. Surgical management of posterior pharyngeal wall carcinomas: Functional and oncologic results. Head Neck. 2001;23:80–86.
3.Nakatsuka T, Harii K, Ueda K, et al. Preservation of the larynx after resection of a carcinoma of the posterior wall of the hypopharynx: Versatility of a free flap patch graft. Head Neck. 1997;19:137–142.
4.Bakamjian V, Littlewood M. Cervical skin flaps for intraoral and pharyngeal repair following cancer surgery. Br J Plast Surg. 1964;17:191–210.

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