Secondary Logo

Journal Logo

Reliable Option for Salvage Pharyngoesophageal Reconstruction

Miyamoto, Shimpei M.D.; Sakuraba, Minoru M.D.; Nagamatsu, Shogo M.D.

Plastic and Reconstructive Surgery: April 2011 - Volume 127 - Issue 4 - p 1734-1735
doi: 10.1097/PRS.0b013e31820a6432

Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital East; Kashiwa, Japan

Correspondence to Dr. Miyamoto, Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan,

Back to Top | Article Outline


We read with interest the article entitled “Complex Salvage of a Failed Pharyngoesophageal Reconstruction with Impending Airway Disaster” (Plast Reconstr Surg. 2010;125:208e–210e) by Hsu and Yu. Although the authors should be applauded for their successful salvage of such a complicated case, we would like to point out several issues associated with their resection and reconstruction plans.

A major problem of the resection included the preservation of the posterior wall of the pharynx. If primary closure of the mucosal defect is not possible and a free flap transfer is required, the resection should be circumferential to simplify the reconstructive procedure. Although the remaining mucosa may help to prevent stricture formation, the fistula rate for partial resections has been shown to be higher than that for circumferential ones, regardless of the method of reconstruction.1,2

Flap selection is also an important consideration. Indications for use of an anterolateral thigh flap for pharyngoesophageal reconstruction have recently expanded because of low donor-site morbidity and good speech function with tracheoesophageal puncture.3 However, the safety of fasciocutaneous flaps in previously irradiated patients has not yet been established.1,4 In salvage cases, pharyngocutaneous fistulas, even minor ones, can lead to life-threatening conditions, as seen in the described case, and prevention of fistula formation and secure wound closure should take precedence over postoperative function. Several reports have recommended the preferential use of enteric flaps for salvage pharyngoesophageal reconstruction in patients able to tolerate a laparotomy, because of their excellent wound healing properties.1,5

In our opinion, the optimal reconstructive option for the patient was circumferential reconstruction with free jejunum transfer and neck skin resurfacing with a regional flap. Although several regional flaps can be used (e.g., deltopectoral or pectoralis major myocutaneous flaps), we prefer the pectoralis major muscle flap with a skin graft on the muscle (Figs. 1 and 2). If a skin defect just cranial to the permanent tracheostoma is reconstructed with a skin island, even a thin flap will overhang the stoma, resulting in prolonged endotracheal intubation. Using this method, the pectoralis major muscle becomes atrophic and patency of the stoma is maintained. This method can be used safely, even in female patients, with minimal breast deformity.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Shimpei Miyamoto, M.D.

Minoru Sakuraba, M.D.

Shogo Nagamatsu, M.D.

Division of Plastic and Reconstructive Surgery

National Cancer Center Hospital East

Kashiwa, Japan

Back to Top | Article Outline


The authors have no financial interest to declare in relation to the content of this communication.

Back to Top | Article Outline


1. Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope 2006;116:173–181.
2. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: A critical review of the literature. J Plast Reconstr Aesthet Surg. 2008;61:1148–1156.
3. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: A clinical and functional outcomes study. Plast Reconstr Surg. 2005;116:1845–1855.
4. Nakatsuka T, Harii K, Asato H, Ebihara S, Yoshizumi T, Saikawa M. Comparative evaluation in pharyngo-oesophageal reconstruction: Radial forearm flap compared with jejunal flap–-A 10-year experience. Scand J Plast Reconstr Surg Hand Surg. 1998;32:307–310.
5. Patel RS, Makitie AA, Goldstein D, et al. Morbidity and functional outcomes following gastro-omental free flap reconstruction of circumferential pharyngeal defects. Head Neck 2009;31:655–663.

Section Description


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2011American Society of Plastic Surgeons