Grabb’s Encyclopedia of Flaps Head and Neck

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Chapter 219
Trapezoidal Paddle Pectoralis Major Myocutaneous Flap for
Esophageal Replacement
B. STRAUCH
C. SILVER
R. FEINGOLD
A. SHEKTMAN
EDITORIAL COMMENT
The pectoralis major myocutaneous flap for intraoral reconstruction has a high failure rate caused mainly by
inadequate positioning of the skin paddle. The trapezoidal design of the skin paddle, which is placed
entirely over the pectoralis major muscle, gives assurance of excellent viability and decreases the
complications of intraoral skin necrosis. This alternative is useful in free-flap resurfacing intraorally.
The trapezoidal paddle pectoralis major myocutaneous flap is especially useful for circumferential
hypopharyngeal defects and for esophageal reconstruction in elderly patients. It is preferred by the authors to
free jejunal autografts.
INDICATIONS
Reconstruction of circumferential defects of the hypopharynx and cervical esophagus remains a challenge.
Correction can be accomplished with the use of pedicled myocutaneous flaps or with the use of
microvascular free flaps. The trapezoidal paddle pectoralis major myocutaneous flap (TPPMMC) is
recommended and preferred for its ease of performance over free jejunal flaps, for the rapidity of surgery,
and for the absence of an intraperitoneal approach.
Generally, malignant disease in this area carries a poor prognosis; therefore, surgical intervention
frequently assumes only a palliative role. For this purpose, a procedure needs to have a low rate of major
complications and also should allow the patient to return to a normal or near-normal lifestyle as soon as
possible after surgery. Reconstructive efforts should be easily executed, should require little in the way of
expensive equipment, and should conserve hospital resources. The trapezoidal paddle pectoralis major
myocutaneous flap represents such a procedure.
ANATOMY
The pectoralis major is a type-V muscle, with its dominant vascular supply coming from the pectoral branch of the
thoracoacromial artery running on its undersurface. The skin island and muscle are raised together using the
origin of the thoracoacromial vessels at the clavicle as the axis of rotation. All the skin attached to the muscle will
survive elevation as a myocutaneous flap.
FLAP DESIGN AND DIMENSIONS
The skin island is drawn on the chest wall as a trapezoid, with the shorter parallel side superiorly and the longer

parallel side inferiorly. It is situated entirely over muscle with no “random” portion. The height of the trapezoid
corresponds to the length of the pharyngoesophageal defect. Once tubed and transposed, the superior narrow
base of the trapezoid will become situated in the inferior pole of the defect to be anastomosed to the esophagus.
Therefore, the width of this component of the trapezoid must correspond to the diameter of the esophagus.
Because this distal suture line represents the narrowest portion of the reconstruction, an 8-cm width is usually
required to prevent stricture. After transposition, the inferior wider base of the trapezoid will become situated in
the superior pole of the defect, to be anastomosed to the oropharynx. Thus, the width of this component of the
trapezoid must correspond to the diameter of the oropharynx.
OPERATIVE TECHNIQUE
After the extirpative part of the procedure is completed, the resultant defect is measured. The vertical height of
the defect will become the vertical height of the trapezoidal paddle. The skin paddle is outlined on the chest wall
in a trapezoidal shape, with the long edge of the paddle placed inferiorly and the short edge placed superiorly
(Fig. 219.1). The length of these edges should be equal to the circumference of the oropharyngeal and
esophageal remnants. The skin paddle should lie entirely over the pectoralis major muscle. No “random” portion
should be created.
FIGURE 219.1 After extirpation, resultant defect is measured. Vertical defect height will become vertical height of
the trapezoidal paddle. Skin paddle is outlined on chest wall in trapezoidal shape, with the long edge of the
paddle placed inferiorly, and the short edge is placed superiorly.
FIGURE 219.2 Flap should be tubed before proximal and distal anastomoses. Long suture line should be lateral
and muscle placed over the skin tube.

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Once the skin paddle is incised down to the pectoralis fascia, the muscle itself is mobilized, and the entire
musculocutaneous flap is rotated into the neck. The flap should be tubed before performing the proximal and
distal anastomoses, the long suture line placed laterally (Figs. 219.2, 219.3, 219.4), and the muscle placed over
the skin tube. The pectoralis major muscle is sutured to the surrounding tissue for support. A split-thickness skin
graft is placed on any of the externally exposed muscles, and the chest wound is closed primarily.
CLINICAL RESULTS
Among the ten consecutive patients in a series who underwent hypopharyngeal reconstruction with the
TPPMMC flap, no flap loss occurred in any of the patients. Normal or near-normal swallowing was attained
by all patients. The time to deglutition was 1 to 3 weeks for nonirradiated patients, and 3 to 13 weeks for
irradiated patients. Fistulas developed in four patients, all of whom had been previously irradiated. Two of
the four fistulas healed with conservative management. One stenosis developed in this series and was
treated successfully by a single dilation.
Compared with results of free jejunal transfers (1, 2, 3, 4, 5, 6), the TPPMMC flaps had an appreciable
advantage in the rate of flap loss (i.e., 3.0 to 1.5% versus 3.0 to 13.5%), respectively. The TPPMMC flap
also has a relative ease of execution, with an average operating time of 2.5 to 3.0 hours, compared with an
average of 6.0 to 6.5 hours for the free jejunal graft. Use of the flap also avoids the morbidity associated
with opening the peritoneal cavity to harvest the jejunal graft or performing a bowel anastomosis (7).
Because many patients in all the series reported are in the advanced-age category, decrease in operating
time and the elimination of an intraabdominal procedure weigh heavily in favor of the pedicled procedure.
Because of the anatomy of the TPPMMC flap, the attached muscle serves to cover the suture line closure.
This normal muscle cover is lacking in jejunal and free radial forearm flap reconstructions (8).
FIGURE 219.3 Muscle and skin paddle are passed subcutaneously into the neck wound. The inferior
anastomosis is begun.

SUMMARY
The trapezoidal paddle pectoralis major myocutaneous flap has predictably good results and low
complication rates, and it requires a relatively short operating time. Compared with free jejunal grafts, it
holds a promising position in reconstruction of postextirpative defects of the hypopharynx and cervical
esophagus.
FIGURE 219.4 Superior repair (the larger circumference) is now closed. Muscle flap is sutured over the
neck wound. Any remaining defect not covered with the skin flap is skin grafted.
References
1. Coleman JJ, III. Reconstruction of the pharynx after resection for cancer. Ann Surg 1989;209:554.
2. Coleman JJ, III, Tan K-C, Searles JM, et al. Jejunal free autograft: analysis of complications and their
resolution. Plast Reconstr Surg 1989;84:589.
3. Reece GP, Schusterman MA, Miller MJ, et al. Morbidity and functional outcome of free jejunal transfer
reconstructions for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg
1995;96:1307.
4. Cusumano RJ, Silver CE, Brauer RJ, Strauch B. Pectoralis myocutaneous flap for replacement of cervical
esophagus. Head Neck 1989;11:450.

5. Silver CE, Cusumano RJ, Fell SC, Strauch B. Replacement of upper esophagus: results with
myocutaneous flap and with gastric transposition. Laryngoscope 1990;99:819.
6. Coleman JJ, III. Jejunal free flap. In: Strauch B, Vasconez L, Hall-Findlay E, eds. Grabb's encyclopedia of
flaps, 2nd ed. Philadelphia: Lippincott-Raven, 1998; Chap. 204.
7. Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis major myocutaneous flap in
head and neck reconstruction. Am J Surg 1990; 160:352.
8. Boyd JB. Radial forearm cutaneous flap for hypopharyngeal reconstruction. In: Strauch B, Vasconez L,
Hall-Findlay E, eds. Grabb's encyclopedia of flaps, 2nd ed. Philadelphia: Lippincott-Raven, 1998; Chap. 207.

Chapter 220
Supraclavicular Artery Island Flap
MICHAEL W. CHU
ERNEST S. CHIU
EDITORIAL COMMENT
The mobility of this flap has been widely extended with proximal dissection of the vasculature. It is less
bulky than the PM flap and can be rotated up to 180 degrees.
INTRODUCTION
The supraclavicular flap is based on the supraclavicular artery, which is a branch from the transverse cervical
artery that originates from the thyrocervical trunk. Kazanjian and Converse (1) first described the supraclavicular
flap in 1949 and referred it as the acromial flap. In 1983, Lamberty (2) named it the supraclavicular artery flap
and the flap was widely published until it fell out of favor when it was criticized by Blevins and Luce (3) for a high
incidence of distal flap necrosis.
Recent trends in reconstructive surgery to minimize donor site morbidity and the advent of perforator flaps have
popularized the supraclavicular artery island flap (SCAIF) again. Previous concerns of distal tip ischemia have
been addressed with modifications in operative technique, cadaveric perfusion studies (4), and radiographic
imaging (5).
INDICATIONS
The supraclavicular flap is a thin, pliable, fasciocutaneous flap for neck, cervicofacial, and anterior chest
wall reconstruction. It is also an option for patients who are not candidates for microvascular free flaps. The
supraclavicular flap has been used to reconstruct circumferential pharyngeal (6), parotidectomy (7), and
scapular defects (8), as well as cervicofacial and mentosternal burn contractures (9); chest wall (10) and
anterior, middle, and posterior skull base defects (11, 12); tracheostomal reconstruction (13); and intraoral
resurfacing (14). It can be used as an axial, rotational, transposition, interpolated, or turnover flap, as well
as a free tissue transfer. The SCAIF can be used to import vascular inflow, fill volumetric defects, or provide
cutaneous coverage for head and neck defects.
An advantage of the supraclavicular fasciocutaneous flap is it is not as bulky as a musculocutaneous flap,
such as the pectoralis major flap, which is essential in tracheostoma reconstructions to avoid narrowing the
airway or obstructing tracheoesophageal prostheses used in esophageal speech. A disadvantage of the
SCAIF is that the vascularity of the flap is most tenuous at the distal portion, which is usually where a
vascularized flap is most needed.
Relative contraindications for the supraclavicular flap are prior history of cervical lymphadenectomy and
neck irradiation because of concern for injury to the supraclavicular artery. However, the transverse cervical
artery has been shown to be fairly reliable despite prior radiation or neck dissection (15).
ANATOMY
The supraclavicular artery is a branch of the transverse cervical artery that originates from the thyrocervical

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trunk. It can be reliably found in the supraclavicular triangle between the sternocleidomastoid, clavicles, and
trapezius (Fig. 220.1). On rare occasion, it can originate from the subclavian, internal mammary, or the
suprascapular artery (16, 17).
The supraclavicular artery has a diameter of 1.1 to 1.5 mm and pedicle length of 1 to 7 cm in length and is
located 3.6 cm above the clavicle and 8.6 cm from the sternoclavicular joint (10). The mean perfused paddle
length is 24.2 cm and width is 8.7 cm (10).
The supraclavicular nerves, from cervical roots C3 to C4, exit underneath the sternocleidomastoid muscle and
provide sensation to the supraclavicular skin. These sensory nerves can be harvested with the skin paddle as a
neurotized flap.
FLAP DESIGN
The course of the supraclavicular artery can be marked out with a hand-held Doppler in the triangular space
bordered by the sternocleidomastoid muscle, trapezius muscle, and clavicle (Fig. 220.1A). The artery travels
perpendicular to the transverse cervical artery and courses posteriorly toward the trapezius muscle. A suture can
be fixated at the pivot point to estimate the radius of rotation and skin paddle length. An elliptical skin paddle is
then designed according to the defect and includes an additional 2 to 3 cm of skin proximal to the pedicle origin.
The largest described skin island was in a delayed SCAIF and measured 12 × 35 cm (18), but the width is
recommended to not exceed 7 to 8 cm to allow primary closure, and the length is recommended to not extend
more than 3 cm distal to the acromion. The arc of rotation for the supraclavicular flap has been reported to be up
to 180 degrees (Fig. 220.1D). Routine preoperative radiographic imaging is not done for the SCAIF, but if there is
concern, computed tomographic angiography can be done to confirm patency and size of the supraclavicular
artery.
FIGURE 220.1 A: Diagram of supraclavicular artery flap based on a major perforator of the supraclavicular
artery (circle). Flap dimensions are marked as 28 × 7 cm. B: Supraclavicular artery flap raised with distal tip de-

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epithelialized. The flap is designed as an islandized flap, where the donor site is contiguous with the wound
defect. C: SCAIF flap utilized as a turnover flap for oral cavity reconstruction. D: SCAIF isolated and
demonstrating a wide arc of rotation.
OPERATIVE TECHNIQUES
The skin incision is carried down through the skin and fascia of the anterior deltoid muscle. The SCAIF is then
dissected from distal to proximal in a subfascial plane. A Doppler can be used to confirm vascular flow on the
undersurface of the flap as the dissection proceeds proximally. Blunt dissection and bipolar cautery are used
within 2 cm of the pedicle origin to avoid thermal injury to the vessel. The vascular pedicle is not skeletonized to
avoid unnecessary trauma. The SCAIF can be rotated, transposed, tubed, or interpolated along a wide arc of
rotation as a tunneled or island flap (Fig. 220.1). If the flap is tunneled, care should be taken to prevent kinking or
compression of the pedicle.
We prefer to islandize the flap because it allows greater flap rotation, increases the freedom of flap inset, and
avoids pedicle kinking and torsion. The flap can also be used as a turnover flap (Fig. 220.1C) and the
undersurface of the SCAIF skin grafted. If the supraclavicular flap is interpolated over an intact skin bridge
overlying the pedicle, the pedicle is divided 2 to 3 weeks later.
The surrounding skin of the donor site is widely undermined and can be closed primarily for flaps up to 8 cm
wide. A split-thickness skin graft can be used to close the donor site if tension is excessive. Drains are not
necessary after adequate hemostasis. Tracheostomy ties and pressure around the donor site and vascular
pedicle are to be avoided and dry dressings are used to prevent soilage from tracheostomy secretions.
CLINICAL RESULTS
The SCAIF is a reliable flap with a high success rate (6, 7, 10, 11, 12, 13). The previous concerns with the
unreliable distal portions have been addressed with anatomic and radiographic studies that have defined
the limits of the SCAIF flap (4, 5, 18). The SCAIF
is a fasciocutaneous flap, most often reported as a local rotational flap. Defects that indicate a thin, pliable
flap make this local flap an attractive alternative to more complex microsurgical reconstructive options. The
potential pitfalls of this flap are rotating the flap too much and kinking the pedicle, injury to the pedicle
during dissection, and distal tip ischemia. For these concerns, we recommend avoiding excessive dissection
of the pedicle and leaving a cuff of fascia around the source artery, islandizing the flap to increase the arc of
rotation, and careful patient selection (Figs. 220.2 and 220.3).

FIGURE 220.2 A: Intraoperative view of oral cavity defect after excision of a left cheek squamous cell
carcinoma, with exposed bone of mandibular ramus. B: Four-week postoperative view of reconstruction.
FIGURE 220.3 A: Contralateral view of right oral cavity. B: Twelve-month postoperative view of
supraclavicular artery island flap (red circle), with a thin, confluent buccal mucosal surface and no evidence
of trismus.
SUMMARY
Head and neck wounds are often complex defects that commonly occur in patients with multiple medical
comorbidities and a history of radiation therapy and neck dissection. The SCAIF is a versatile, thin, pliable,
local flap. The SCAIF is not too bulky, does not require microsurgical expertise, and is a safe and effective
reconstructive option in the appropriate patient population.

References
1. Kazanjian VH, Converse JM. The Surgical Treatment of Facial Injuries. Baltimore: Lippincott Williams &
Wilkins, 1949.
2. Lamberty BG, Cormack GC. Misconceptions regarding the cervicohumeral flap. Br J Plast Surg
1983;36(1):60-63.
3. Blevins PK, Luce EA. Limitations of the cervicohumeral flap in head and neck reconstruction. Plast
Reconstr Surg 1980;66(2):220-224.
4. Chan JWH, Wong C, Ward K, et al. Three- and four-dimensional computed tomographic angiography
studies of the supraclavicular artery island flap. Plast Reconstr Surg 2010;125(2):525-531.
5. Adams AS, Wright MJ, Johnston S, et al. The use of multislice CT angiography preoperative study for
supraclavicular artery island flap harvesting. Ann Plast Surg 2012;69(3):312-315.
6. Chiu ES, Liu PH, Baratelli R, et al. Circumferential pharyngoesophageal reconstruction with a
supraclavicular artery island flap. Plast Reconstr Surg 2010;125(1):161-166.
7. Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic
reconstruction: indications, complications, and outcomes. Plast Reconstr Surg 2009;124(1):115-123.
8. Pallua N, Magnus Noah E. The tunneled supraclavicular island flap: an optimized technique for head and
neck reconstruction. Plast Reconstr Surg 2000;105(3):842-851.
9. Pallua N, Machens HG, Rennekampff O, et al. The fasciocutaneous supraclavicular artery island flap for
releasing postburn mentosternal contractures. Plast Reconstr Surg 1997;99(7):1878-1884.
10. Chan JWH, Wong C, Ward K, et al. Three- and four-dimensional computed tomographic angiography
studies of the supraclavicular artery island flap. Plast Reconstr Surg 2010;125(2):525-531.
11. Chiu ES, Kraus D, Bui DT, et al. Anterior and middle cranial fossa skull base reconstruction using
microvascular free tissue techniques: surgical complications and functional outcomes. Ann Plast Surg
2008;60(5):514-520.
12. Pointer DT, Friedlander PL, Amedee RG, et al. Infratemporal fossa reconstruction following total
auriculectomy: an alternative flap option. J Plast Reconstr Aesthet Surg 2010;63(8):e615-e618.
13. Chu MW, Levy JM, Friedlander PL, Chiu ES.Tracheostoma reconstruction with the supraclavicular artery
island flap. Ann Plast Surg. 2015;74(6):677-679.
14. Anand AG, Tran EJ, Hasney CP, et al. Oropharyngeal reconstruction using the supraclavicular artery
island flap: a new flap alternative. Plast Reconstr Surg 2012;129(2):438-441.

15. Yu P. The transverse cervical vessels as recipient vessels for previously treated head and neck cancer
patients. Plast Reconstr Surg 2005;115(5):1253-1258.
16. Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinical studies of the supraclavicular flap: analysis
of 103 flaps used to reconstruct neck scar contractures. Plast Reconstr Surg 2009;123(5):1471-1480.
17. Huelke DF. A study of the transverse cervical and dorsal scapular arteries. Anat Rec 1958;132:233.
18. Di Benedetto G, Aquinati A, Pierangeli M, et al. From the “charretera” to the supraclavicular fascial island
flap: revisitation and further evolution of a controversial flap. Plast Reconstr Surg 2005;115(1):70-76.

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Chapter 221
Bilobed Chest Flap (Deltopectoral Skin Flap and Pectoralis Major
Musculocutaneous Flap)
R. M. MEYER
EDITORIAL COMMENT
Use of an external large flap to cover the esophageal reconstruction may be unnecessary, because the
pectoralis major muscle can be covered and closed easily with a split-thickness skin graft. If this procedure
is attempted with the pectoralis major muscle and the ipsilateral deltopectoral flap is used, then the surgeon
must ensure that the second intercostal vessel is maintained to retain blood supply to the deltopectoral flap.
The bilobed chest flap is a double cutaneous and musculocutaneous flap used for head and neck reconstruction.
The flap incorporates the pectoralis major musculocutaneous flap and the medially based cutaneous
deltopectoral flap in a single bilobed unit. Both flaps come from the ipsilateral chest and provide for both
reconstruction of pharyngoesophageal wall defects and external cutaneous coverage in one stage.
FIGURE 221.1 A,B: Outline of the bilobed flap. (From Meyer et al., ref. 2, with permission.)
INDICATIONS
Solutions to the problem of external coverage at flap donor sites have been numerous, and I have used six
alternative methods, according to the type of repair. In my experience with 78 pectoralis major
musculocutaneous flaps, I have used the following methods for closure or cover of the external defect (1, 2,
3):
1. Skin approximation and suture (21 patients)
2. Using a part of the pectoralis major musculocutaneous flap for two patches (31 patients)
3. Split-thickness skin grafts (18 patients)

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4. Advancement shoulder flaps (4 patients)
5. Contralateral deltopectoral flaps (3 patients)
6. Ipsilateral deltopectoral flap (1 patient)
The last method is the subject of this chapter (i.e., the use of the pectoralis major musculocutaneous flaps
for pharyngoesophageal reconstruction, combined with the ipsilateral medially based deltopectoral flap for
cutaneous coverage). The ipsilateral musculocutaneous and cutaneous flaps, having a common base, thus
form a single bilobed flap.
FLAP DESIGN AND DIMENSIONS
The bilobed chest flap is composed of two standard flaps: the pectoralis major musculocutaneous flap and the
deltopectoral cutaneous flap. The two flaps share a common base, starting approximately 3 to 4 cm below the
medial end of the clavicle and continuing cranially and laterally to the anterior part of the neck. The design of the
two flaps resembles an open V (Fig. 221.1). The outline of the musculocutaneous portion of the bilobed flap
should be centered on the thoracoacromial artery.
OPERATIVE TECHNIQUE
First, the musculocutaneous portion of the bilobed flap is raised to repair the deep neck defect in the
pharyngoesophageal tract after pharyngolaryngectomy. I tailor a new upper digestive tract, making a tube with
the pectoralis major musculocutaneous flap (Figs. 221.2 and 221.3). The reconstruction begins on the lower
side, with the anastomosis to the esophageal remnant. The junction between the mucocutaneous anastomosis
and the vertical suture line, which forms the new digestive tract, is placed laterally. At the end of the vertical
sutures, the flap has a funnel shape, with the inner layer formed by the cutaneous portion of the pectoralis major
flap and the outer one by the muscle
portion. The upper anastomosis then is performed in the same manner as the lower, by joining the flap to the
remaining base of the tongue, as well as to the lateral and posterior pharyngeal walls.
FIGURE 221.2 The lower oblique part of the bilobed flap containing part of the pectoralis major muscle is
sutured to the border of the defect.

FIGURE 221.3 A,B: The anterior and lateral pharyngeal wall from the esophageal mouth up to the base of the
tongue is reconstructed by the pectoralis major musculocutaneous part of the flap. (From Meyer et al., ref. 2, with
permission.)
After this first part of the cervical reconstruction, the previously outlined deltopectoral cutaneous flap is raised
(Fig. 221.4), starting at its lateral edge. It is then rotated to cover the exposed raw surface of the
musculocutaneous flap (Fig. 221.5).
At this time, care must be taken not to dissect this cutaneous portion of the bilobed flap too medially. A medial
base must be preserved in order not to jeopardize the blood supply, which depends on the perforating branches
of the internal mammary artery.
FIGURE 221.4 The donor area of the musculocutaneous part of the flap is closed, and the deltopectoral part of
the flap is raised.
The musculocutaneous lower donor site is closed primarily by joining the edges of the wound. The deltopectoral
donor site is covered with a split-thickness skin graft (Figs. 221.6 and 221.7).
CLINICAL RESULTS
The use of a combined musculocutaneous and cutaneous flap from the ipsilateral chest permits
reconstruction of the cervical pharyngoesophageal tract and simultaneous provision of a pedicled
cutaneous cover in head and neck reconstruction. The considerable length, bulk, and excellent blood
supply of the pectoralis major musculocutaneous flap render it especially appropriate for pharyngeal

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reconstruction. Its use has appreciably reduced the incidence of fistula formation. The deltopectoral
cutaneous flap has the double advantage of being a pedicled cutaneous flap and having its base close to
the recipient site. This composite flap is a true bilobed flap, having the advantages of one-stage
reconstruction without delay and incorporating both musculocutaneous and cutaneous elements from an
ipsilateral donor site.
SUMMARY
The advantages discussed render the bilobed chest flap useful for many cases involving inner and outer
head and neck reconstruction.
FIGURE 221.5 A,B: External coverage by the deltopectoral part of the flap.
FIGURE 221.6 The donor area of the horizontal deltopectoral part of the composite flap is covered by a
split-thickness skin graft. (From Meyer et al., ref. 2, with permission.)

FIGURE 221.7 Result after 4 months (while undergoing endoscopic revaluation).
References
1. Brupbacher JP, Meyer R, Failat ASA, Botta Y. Reconstruction de l'oesophage cervical avec le lambeau
musculo-cutané du grand pectoral. Cah Franc d'Orl 1981;16:639.
2. Meyer R, Kelly TP, Failat ASA. Single bilobed flap for use in head and neck reconstruction. Ann Plast
Surg 1981;6:203.
3. Meyer R, Brupbacher JP, Brown WL. Pharyngoesophageal reconstruction by pectoralis major
myocutaneous flap. Chir Plast 1982;6:249.

Chapter 222
Latissimus Dorsi Musculocutaneous Flap for Pharyngoesophageal
Reconstruction
F. E. BARTON JR.
J. M. KENKEL
W. P. ADAMS JR.
Despite recent advances in microsurgical techniques, regional pedicled flaps remain the mainstay of
reconstructive options for pharyngoesophageal reconstruction. The island pectoralis major musculocutaneous
flap continues to be the preferred flap of many reconstructive surgeons; however, the latissimus dorsi
musculocutaneous flap is a safe and reliable alternative for reconstruction of partial and circumferential cervical
esophageal defects (1, 2, 3).
INDICATIONS
The latissimus dorsi musculocutaneous flap may be used for any one-stage pharyngoesophageal
reconstruction, but it should be considered the flap of choice in patients with large soft-tissue or cutaneous
deficits, infected wounds, or irradiated beds that could not support microvascular transfer. The following are
the advantages of the latissimus dorsi musculocutaneous flap for pharyngoesophageal reconstruction:
1. A large area of skin can be transferred while still closing the donor site primarily.
2. The cutaneous paddle is usually hairless, in contrast to flaps from the anterior chest in men.
3. The donor site is on the back, which is more acceptable to women than donor deformities on the anterior
chest.
4. There is minimal functional loss from latissimus dorsi harvest.
5. The long vascular pedicle allows for a wide arc of rotation that easily reaches the nasopharynx.
6. The flap can be split into separate musculocutaneous units to be used for lining, soft-tissue fill, and skin
cover or to preserve motor function at the flap donor site (4).
7. The vascular pedicle is away from the field of resection or irradiation in head and neck malignancies.
ANATOMY
The latissimus dorsi is a flat muscle extending obliquely across the back. It originates from the lower six thoracic
vertebrae, lumbar and sacral vertebrae, iliac crest, and external surface of the lower four ribs, and it inserts on
the intertubercular groove of the humerus (5, 6). The neurovascular anatomy of the latissimus dorsi flap was
expertly described previously (7, 8, 9, 10, 11). The thoracodorsal artery originates from the subscapular artery
and is the principal blood supply to the latissimus dorsi muscle. One to three arterial branches to the chest wall
are given off before the thoracodorsal artery enters the latissimus dorsi muscle (7). The neurovascular pedicle
enters the muscle on its undersurface about 8 to 10 cm from its origin (8) and 8 to 12 cm below its humeral
insertion. The vessels bifurcate about 2 cm after entering the muscle. The superior branch traverses the muscle
parallel to its border approximately 3.5 cm from the upper edge. The lateral branch parallels the posterior border
of the muscle some 2 cm from its edge (7). Cutaneous perforators emanate from these branches and appear at
regular patterns 3 to 5 cm apart (1, 12, 13). In cadaveric injection studies of the thoracodorsal artery, the lower
third of the muscle and its overlying skin consistently do not fill with contrast medium, which indicates this portion

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of the muscle and skin are unreliable for use as a musculocutaneous flap (1, 12).
FLAP DESIGN AND DIMENSIONS
The vascular status of the musculocutaneous unit is assessed preoperatively. Using a Doppler device, the main
thoracodorsal artery is traced through the lower axilla to its entrance into the latissimus dorsi muscle. The large
anterior branch that parallels the lateral edge of the muscle is identified, and the specific perforating tributaries
from the muscle to the skin are pinpointed. When possible, the cutaneous paddle is placed over the area of
maximum density of perforating vessels.
While a large skin island would inevitably include one or more perforators from the muscle, small flaps used in
pharyngoesophageal reconstruction are specifically placed over identified perforators to ensure survival. The
skin paddle is ideally designed approximately two thirds of the way down the muscle. This location preserves a
reliable vascular supply to the skin and yet allows a wide range of motion of the flap on its pedicle. Alternatively,
a portion of skin from the lower third of the flap may be carried as a random extension of a more superiorly based
island. Skin paddles taken within 8 cm of the posterior iliac crest have been routinely incorporated in large flaps
containing abundant muscle (2). On the other hand, a skin island isolated over the lower third of the muscle may
not be viable.
Because the flap will be rotated 180 degrees when transposed to the neck, the island is diagrammed upside-
down on
the back. A trapezoidal paddle is marked obliquely on the muscle so when the flap is transferred to the neck and
the cutaneous island is oriented vertically, the muscle pedicle will exit inferiorly and laterally (Fig. 222.1).
FIGURE 222.1 Technique of latissimus dorsi musculocutaneous flap esophageal reconstruction.
The size of the cutaneous paddle depends on the size of the esophageal defect. For an entire
cervicoesophageal segment, the island should be 8 cm wide at its cephalic margin (to match the circumference
of the lower esophageal junction) and about 12 cm long caudally. After transfer, an island flap of this size will
yield a lumen of 4 to 5 cm at the hypopharynx and 2 to 2.5 cm in the distal esophagus. Smaller defects not
involving the full esophageal circumference can be repaired with smaller cutaneous islands of proportional size.
OPERATIVE TECHNIQUE
The patient is placed in a semilateral decubitus position that facilitates simultaneous flap elevation and tumor
extirpation. Dissection begins with a transverse axillary incision that is extended down the lateral border of the

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latissimus dorsi muscle (Fig. 222.2). The muscle is bluntly dissected from the serratus muscle anteriorly and the
thoracolumbar vessels to the latissimus are severed. The thoracodorsal neurovascular pedicle is isolated, and
the vessels to the serratus anterior and teres major are ligated and divided. The thoracodorsal artery and vein
are skeletonized up to the level of the circumflex scapular vessels, which are left intact to provide collateral flow
and to tether the pedicle so that it will not kink. The thoracodorsal nerve is transected to promote atrophy of the
muscle postoperatively. Hyperabduction of the upper extremity may injure the brachial plexus and should be
avoided (14).
The skin island is incised circumferentially down to muscle fascia, and the remaining skin is reflected off the
muscle. The muscle, with its attached island, then is freed distally, dissected in a retrograde fashion, and cut at
its humeral insertion to increase the arc of rotation. A heavy suture is placed in the lateral muscle and secured to
the pectoralis minor muscle or chest wall. This suture prevents stretch injury and torsion of the pedicle and
improves control and countertraction during transfer of the flap to the neck (14).
A tunnel is created between the pectoralis major and minor muscles, penetrating the pectoralis major to exit over
the clavicle and enter the cervical area. The pectoralis tunnel is made medial to the thoracoacromial pedicle. The
tendinous insertion of the pectoralis minor can be transected to prevent compression of the vascular pedicle of
the flap as it courses between these two muscles (14). Care is taken to preserve the neurovascular supply of the
pectoralis major muscle during preparation of the intermuscular tunnel. The donor site on the back is closed
primarily.
Inset of the latissimus dorsi musculocutaneous flap is similar to that of other flaps. If a partial esophageal
circumference is needed, the skin island is sutured to the mucosal remnant. In the event of circumferential
esophageal loss, the skin island is tubed, the upper end is sutured to the hypopharynx, and the lower end is
sutured to the distal esophagus. For combined pharyngeal and cervical or buccal defects, the latissimus dorsi
flap can be split based on its consistent medial and lateral arterial branches (4). Postoperative stricture is
avoided by rounding the edge of the flap in the hypopharynx to create a wide-mouthed funnel effect and by
spatulating the distal anastomosis with a triangular extension of the flap set into an incised esophageal wall (Fig.
222.1). The latissimus dorsi muscle also can be used as a second-layer closure over the mucosal suture line or
to cover one or both carotid vessels by securing the flap to the prevertebral fascia.
CLINICAL RESULTS
The senior author's experience with the latissimus dorsi musculocutaneous flap in pharyngoesophageal
reconstruction was reported previously (1). In that series, the latissimus dorsi musculocutaneous flap was
found to be most useful for replacement of large amounts of vascularized tissue when previous
surgery or irradiation precludes the use of local flaps. The latissimus dorsi musculocutaneous flap was
preferred over the pectoralis musculocutaneous flap because the skin of the back is usually hairless and
thus better suited for intraoral lining. In addition, the donor defect of the latissimus dorsi musculocutaneous
flap was more acceptable to patients than the deficit caused by elevation of other regional flaps from the
anterior trunk. The pectoralis major flap, for instance, produces an unsightly infraclavicular hollow and an
absent anterior axillary fold that many women find disagreeable.

FIGURE 222.2 A 40-year-old woman with extensive squamous-cell carcinoma of the piriform sinus and
esophagus underwent laryngopharyngectomy and reconstruction of the segmental cervical esophagus with
the latissimus dorsi island musculocutaneous flap. A: Operative defect. Note the circumferential esophageal
loss between arrows. B: Design of the latissimus cutaneous paddle on the back. Note cutaneous
perforators. C: Completion of replacement of cervical esophagus with the tubed cutaneous paddle. D:
Postoperative appearance. E: Postoperative donor-site defect. F: Lateral cervical esophagogram with
arrows indicating the reconstructed segment.
Disadvantages of the latissimus dorsi musculocutaneous flap for use in head and neck reconstruction
include the following:
1. Flap dissection and elevation must be done with the patient in the semilateral position, which may require
intraoperative repositioning.
2. Dissection of the neurovascular pedicle must be done through a separate axillary incision and can be
somewhat tedious.
3. The flap may be bulky and too thick for small esophageal defects, especially in obese patients.
4. Neuropraxia of the brachial plexus can occur if the shoulder is not carefully supported during flap harvest.

SUMMARY
The latissimus dorsi musculocutaneous flap is an excellent option in pharyngoesophageal reconstruction. It
provides generous amounts of hairless skin and muscle while producing an acceptable donor defect.
References
1. Barton FE Jr, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous
flap: anatomical observations and report of 60 cases. Plast Reconstr Surg 1983;71:199.
2. Watson JS, Lendrum J. One stage pharyngeal reconstruction using a compound latissimus dorsi island
flap. Br J Plast Surg 1981;34:87.
3. Yamamoto K, Yokota K, Higaki K. Entire pharyngoesophageal reconstruction with latissimus dorsi
myocutaneous island flap. Head Neck Surg 1985;7:461.
4. Tobin GR, Moberg AW, DuBou RH, et al. The split latissimus dorsi myocutaneous flap. Ann Plast Surg
1981;7:637.
5. Hollinshead WH. Textbook of anatomy, 2nd ed. New York: Harper & Row, 1967.
6. Spalteholz W. Hand-Atlas of human anatomy, 7th ed. Philadelphia: Lippincott, 1943; vol 2.
7. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631.
8. Tobin GR, Schusterman M, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.
9. Cassel JM. Intramuscular anatomy of the latissimus dorsi muscle. Br J Plast Surg 1989;42:607.
10. Rowsell AR, Eisenberg N, Davies DM, et al. The anatomy of the thoracodorsal artery within the
latissimus dorsi muscle. Br J Plast Surg 1986;39:206.
11. Rowsell AR, Davies DM, Eisenberg N, et al. The anatomy of the subscapular-thoracodorsal arterial
system: study of 100 cadaver dissections. Br J Plast Surg 1984;37:574.
12. Watson JS, Craig RDP, Orton CI. The free latissimus dorsi myocutaneous flap. Plast Reconstr Surg
1979;64:299.
13. Saijo M. The vascular territories of the dorsal trunk: a reappraisal for potential flap donor sites. Br J Plast
Surg 1978;31:200.
14. Sabatier RE, Bakamjian VY, Carter WL. Craniofacial and head and neck applications of the transaxillary
latissimus dorsi flap. Ear Nose Throat J 1992;71:173.

(Trang không có chữ)

Chapter 223
Sternocleidomastoid Muscle and Musculocutaneous Flaps
S. ARIYAN
A one-stage repair of cervical esophagostomes can be performed using an inferiorly based sternocleidomastoid
flap for inner lining and a trapezius musculocutaneous flap for the outer covering of the neck. The
sternocleidomastoid muscle can provide a second layer of closure to protect the neck contents from salivary
leakage. Although this muscle may be covered with a skin graft to facilitate the reconstruction, a trapezius
musculocutaneous flap provides a more naturally textured covering for the neck (Fig. 223.1) (1).
See Chapter 194 for a description of the flap.
FIGURE 223.1 A: A large cervical esophagostome (left) may be reconstructed with the turnover of an inferiorly
based SCM flap (right). B: In this case, outer covering was provided with a trapezius musculocutaneous flap.
(From Ariyan, ref. 1, with permission.)
Reference
1. Ariyan S. One-stage repair of a cervical esophagostome with two myocutaneous flaps from the neck and
shoulder. Plast Reconstr Surg 1979;63:426.

Chapter 224
Reconstruction of The Cervical Esophagus by Visceral
Interposition
C. E. SILVER
R. J. BRAUER
Various segments of abdominal viscera may be transposed or freely transplanted to replace portions of
esophagus after resection or stenosis. The main advantage of these procedures, compared to reconstructions
using skin (see Chapter 215), is that considerably longer segments of esophagus can be replaced. Visceral
interpositions often can be performed in a single stage, thus permitting rapid rehabilitation of the
esophagectomized patient; however, the magnitude of surgical trauma is generally greater than with skin
reconstructions, and potentially disastrous complications may occur in association with necrosis or anastomotic
failure. Thus, a greater degree of risk is assumed with these procedures than with reconstructions using skin to
replace esophagus.
INDICATIONS
Reversed Gastric Tube
An antiperistaltic gastric tube (1) has been found to have several advantages over isoperistaltic tubes (2, 3,
4), including greater length, simplicity, and versatility, and has been more widely employed (Fig. 224.1).
Esophagocoloplasty
The colon generally provides a slightly shorter conduit than can be created by a reversed gastric tube and
is more difficult to transfer subcutaneously. Thus, we tend to use colon more often in patients in whom
substernal transfer is feasible or in whom anastomosis to the lower cervical esophagus is required (5) (Fig.
224.2).
Despite arguments advanced by advocates of either esophagocoloplasty or gastric tube esophagoplasty,
the choice of procedure depends more on the experience and familiarity of the individual surgeon with either
method than on any marked inherent advantage of one over the other.
Gastric Transposition (Gastric Pull-Up)
The gastric pull-up operation offers several advantages over other visceral interpositional procedures (6, 7,
8, 9, 10, 11). The blood supply of the transposed stomach is superior to that of colon and reversed gastric
tube. The procedure is performed in one stage, and the only anastomosis is extraabdominal, which lessens
the chance of peritonitis or mediastinitis. The pharyngogastric anastomosis is particularly resistant to
strictures and dehiscence. Elimination of the thoracotomy markedly lessens the morbidity and mortality of
the procedure. When employed in properly selected patients, the gastric transposition operation comes
close to being the ideal method for pharyngoesophageal reconstruction (see Chapter 215). There are,
however, limitations.
The gastric transposition operation for resection and reconstruction of cervical esophageal carcinoma
combines the advantages of two concepts. The scope of resection is increased by including extrathoracic
extraction of the entire esophagus with the resection. Reconstruction is then accomplished by pulling the
entire stomach through the posterior mediastinal bed of the resected esophagus to the level of the pharynx,
to which it is anastomosed. The procedure is performed in a single stage and is technically simpler than
other methods of visceral interposition. The well-vascularized stomach is a most reliable esophageal

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substitute (Fig. 224.3).
Free Jejunal Transfer
See Chapter 225.
ANATOMY
Reversed Gastric Tube
The reversed gastric tube is pedicled at the fundic end of the stomach and is based on the left gastroepiploic
vessels. With splenectomy and mobilization of the tail of the pancreas, a sufficiently long conduit can be
developed to easily reach the level of the oropharynx (Fig. 224.1).
Esophagocoloplasty
Both right and left colon can be used for esophageal replacement. In theory, the right colon has the advantage of
assuming an isoperistaltic orientation after interposition; however, a great length of the left colon can be pedicled
on the middle colic vessels, and angiographic studies (12) confirmed that the
marginal artery of the colon is more consistent on the left side. Although the left colon assumes an antiperistaltic
orientation when interposed, this has not proven functionally significant (Fig. 224.2).
FIGURE 224.1 Reverse gastric tube esophagoplasty. A: Pedicled tube from greater curvature. B: Final position
of tube with anastomoses to pharynx. C: Alternate routes for tubed transfer to neck (subcutaneous, substernal,
and posterior mediastinal). (From Silver, ref. 13, with permission.)

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FIGURE 224.2 Esophagocoloplasty (left colon). A: Blood supply of colon—outline of transposed segment. B:
Colon mobilized. C: Final position of interposed colon. (From Silver, ref. 13, with permission.)
Gastric Transposition
Blunt digital dissection from abdominal and cervical incisions is used to mobilize the esophagus without a
thoracotomy. The stomach is drawn through the posterior mediastinum by traction on the esophagus. The
transposed stomach receives its blood supply from the right gastric and gastroepiploic vessels (Fig. 224.3).
OPERATIVE TECHNIQUE
Reversed Gastric Tube
The procedure (13) may be performed in one stage, with the resection using two surgical teams, or it may be
employed as a secondary procedure at an interval following esophagectomy and creation of a temporary
pharyngostoma. The abdomen is entered through an upper midline abdominal incision, the gastrocolic and
gastrosplenic ligaments are divided, and a splenectomy is performed. A pedicled tube is created along the
greater curvature of the stomach using a stapling device (Fig. 224.1). Care is taken at all times to preserve the
gastroepiploic vessels. A pyloroplasty is performed to improve gastric emptying.
The tube may be transferred to the neck by means of a substernal, posterior mediastinal, or subcutaneous route
(Fig. 224.1B and C). Although the posterior mediastinal route
(used after total esophagectomy) is shortest, the substernal route has been most often employed. For secondary
reconstruction, the subcutaneous route must be used because of obliteration of mediastinal tissue planes. The
subcutaneous route, although longer than the others, has the advantage of safety in that the mediastinal
contents are not threatened by massive infection in the event of necrosis or dehiscence.
Left Colon Esophagocoloplasty
An isolated loop of bowel, supplied by the middle colic vessels, is created by dividing the superior left colic artery
and the anastomotic connections between the middle colic and right colic and superior and inferior branches of
the left colic artery (Fig. 224.2A) (13). The bowel is mobilized by dissecting the greater omentum from the colon
and by dividing the gastrocolic and phrenocolic ligaments and lateral peritoneal reflections (Fig. 224.2B). Care is

taken while mobilizing the bowel to protect its marginal circulation. The bowel is brought posterior to the stomach
(to avoid creating an obstructive band) and is transposed to the neck. The same routes are used for transfer to
the neck as with the gastric tube, although the substernal route has been the most popular. The distal end of the
colon is brought through the tunnel first and is anastomosed to the oropharynx or cervical esophagus. The
proximal colon (which has now become distal “esophagus”) is anastomosed to the lesser curvature of the
stomach as close to the fundus as possible. A pyloroplasty is performed to enhance gastric emptying. A
colocolostomy is performed to restore bowel continuity.
Gastric Transposition
After resectability of the lesion has been established by cervical exploration, the abdomen is entered through an
upper midline incision by a second surgical team working simultaneously (13, 14). The left gastric, short gastric,
and left gastroepiploic vessels are divided (Fig. 224.3A). Mobilization of the stomach continues by dividing the
gastrocolic and gastrosplenic ligaments without compromising the arcade of the gastroepiploic vessels on the
greater curvature. Preservation of venous drainage is as critical as arterial preservation. Particular care must be
exercised to avoid injuring the right gastroepiploic vein. The gastroesophageal junction is mobilized, the vagus
nerves are transected, the esophageal hiatus is enlarged, and a Kocher maneuver is performed to free the
duodenum. A pyloroplasty is mandatory, owing to vagal resection.
FIGURE 224.3 Gastric transposition or pull-up. A: Blood supply of stomach mobilized for transposition. B:
Stomach transposed through posterior mediastinum. C: Pharyngogastric anastomosis. (From Silver, ref. 13, with
permission.)
The thoracic esophagus is mobilized by blunt digital dissection from the cervical and abdominal incisions. The
delicate posterior tracheal wall is separated with extreme care to prevent disruption, which can be life
threatening. The endotracheal balloon should be deflated before separating the party wall of trachea and
esophagus to prevent pressure from the balloon from being transmitted to the tracheal wall, causing or extending
a tear. A ring dissector (11) or a vein stripper (13) may be used to facilitate esophageal dissection. When the
esophagus has been fully mobilized, the abdominal surgeon feeds the stomach into the posterior mediastinum,
while the cervical surgeon gently pulls the esophagus. A no. 28 French tube inserted in the esophagus and
secured with sutures may facilitate this maneuver. When the stomach assumes its final position, the pylorus is at
the level of the xiphoid and the cardioesophageal junction is at the sternal notch (Fig. 224.3B). The
cardioesophageal junction is transected and closed with staples or continuous suture. A two-layer
pharyngogastric anastomosis is created in the dome of the fundus (Fig. 224.3C).

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CLINICAL RESULTS
Reversed Gastric Tube
Anastomotic fistulas and strictures are the most common complications of reversed gastric tube
esophagoplasty (3, 15). Peptic ulceration has been reported after the procedure (16). The incidence of
anastomotic failure possibly may be reduced with a technique that involves separate incision and suture of
the seromuscular and mucosal layers (17). A major limitation in the usefulness of this procedure is that the
operation is extensive and technically difficult. We found the procedure more useful
for secondary reconstruction in patients who had previously undergone resection than as a one-stage
procedure (1, 13, 18). In six patients in whom this technique was used, there was effective palliation in five,
with one surgical mortality (13).
Esophagocoloplasty
The problems encountered with esophagocoloplasty are due to the relatively poor blood supply, the
difficulty of mobilizing a sufficiently long segment of colon, and the magnitude of the procedure. Necrosis of
the colon and anastomotic leakage or dehiscence with resulting infection are the most common
complications. A distinct disadvantage of esophagocolostomy, in comparison with other procedures, is the
number of anastomoses (esophagocolostomy, gastrocolostomy, colocolostomy, and pyloroplasty) that must
be performed, thus increasing operating time, as well as the risk of anastomotic failure at each site. In three
colon interpositions for reconstruction after pharyngolaryngectomy (13), there was one surgical mortality. In
another series of 14 colon interpositions (19), 10 patients were able to swallow.
Gastric Transposition
The limiting factor for gastric transposition is upward extension of the tumor. While the gastric fundus easily
reaches the level of the hyoid bone, anastomosis attempted above this level may result in excessive tension
on the suture line with resultant disruption. Creation of a gastric flap can increase the upward reach of the
stomach, but such a procedure is technically complex and prone to complications. Thus we do not
recommend gastric transposition for esophageal replacement if the level of resection extends above the
hyoid bone.
Gastroduodenal ulcers, tumors, and previous gastric surgery may preclude the use of stomach for
esophageal replacement. A major disadvantage is that the procedure is suitable only as a one-stage
operation (20) and thus may be employed only in patients who are in suitably good condition.
Complications include tears in the posterior tracheal wall, pneumothorax, hemorrhage, pleural effusions,
peritonitis, mediastinitis, fistulas, and delayed rupture of the great vessels. The transposed stomach will
usually tamponade vessels and raw surfaces within the mediastinum. Because of the absence of a major
intraabdominal anastomosis, peritonitis and mediastinitis occur less frequently than with other abdominal
organ transpositions.
In the combined results in five series of patients (13) totaling 120 gastric transposition operations, there was
an operative mortality of 12% and satisfactory results in 56%. Well-motivated patients can develop
esophageal speech after the procedure (21). There are generally few problems with swallowing (11, 21).
SUMMARY
The cervical esophagus can be reconstructed with various techniques using visceral interposition. These
involve a reversed gastric tube, a left colon esophagocoloplasty, and a gastric pull-up procedure. The free

jejunal transfer is discussed in Chapter 225.
References
1. Heimlich B. Reversed gastric tube esophagoplasty for failure of colon, jejunum and prosthetic
interpositions. Ann Surg 1975;182:154.
2. Ong GB. The Kirschner operation: a forgotten procedure. Br J Surg 1973;60:221.
3. Postlethwait RW. Technique for isoperistaltic gastric tube for esophageal bypass. Ann Surg 1979;189:673.
4. Yamato T, Hamanaka Y, Hirata S, et al. Esophagoplasty with an autogenous tubed gastric flap. Am J Surg
1959;137:597.
5. Goligher JC, Robin IG. Use of left colon for reconstruction of the pharynx and esophagus after
pharyngectomy. Br J Surg 1954;42:283.
6. Ong GB, Lee TC. Pharyngogastric anastomosis after oesophagopharyngectomy for carcinoma of the
hypopharynx and cervical esophagus. Br J Surg 1960;48:193.
7. LeQuesne LP, Ranger D. Pharyngolaryngectomy with immediate pharyngogastric anastomosis. Br J Surg
1966;53:105.
8. Silver CE. Gastric pull-up operation for replacement of the cervical portion of the esophagus. Surg
Gynecol Obstet 1976;142:243.
9. Stell PM. Esophageal replacement by transposed stomach. Arch Otolaryngol 1970;91:166.
10. Leonard JR, Maran AG. Reconstruction of the cervical esophagus via gastric anastomosis.
Laryngoscope 1970;80:849.
11. Akiyama H, Hiyama M, Miyazono H. Total esophageal reconstruction after extraction of the esophagus.
Ann Surg 1975;182:547.
12. Ventemiglia R, Khalil KG, Frazier OH, et al. The role of preoperative mesenteric arteriography in colon
interposition. J Thorac Cardiovasc Surg 1977;74:98.
13. Silver CE. Surgery for cancer of the larynx and related structures. New York: Churchill-Livingstone,
1981.
14. Silver CE. The gastric transposition operation for replacement of cervical esophagus. In: Cohn LH, ed.
Cardiac/thoracic surgery, Vol. 1, Modern techniques in surgery. Mt. Kisco, NY: Futura, 1981.
15. Ein SH, Shandling B, Simpson JS, et al. Fourteen years of gastric tubes. J Pediatr Surg 1978;13:638.

16. Gozner A, Stanciu D, Kirilla A, et al. Ulcer on the presternal tube after esophagoplasty of the greater
curvature of the stomach. Rev Chir 1978;27:213.
17. Sugimachi K, Yaeta A, Ueo H, et al. A safer and more reliable operative technique for esophageal
reconstruction using a gastric tube. Am J Surg 1980;140:471.
18. Silver CE. Reconstruction after pharyngolaryngectomy—esophagectomy. Am J Surg 1976;132:428.
19. DeSanto LW, Carpenter RJ. Reconstruction of the pharynx and upper esophagus after resection for
cancer. Head Neck Surg 1980;2:369.
20. Silver CE. Surgical management of neoplasms of the larynx, hypopharynx and cervical esophagus. Curr
Probl Surg 1977;14:1.
21. Harrison KFN. Rehabilitation problems after pharyngogastric anastomosis. Arch Otolaryngol
1978;104:244.

Chapter 225
Microvascular Free Transfer of Intestine
R. S. STAHL
M. J. JURKIEWICZ
The aggressiveness of pharyngoesophageal malignancies and strictures makes unencumbered wide resection
and effective palliation essential goals in their treatment. It is applications such as these for which microvascular
free transfers of intestine are well suited (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16).
INDICATIONS
Because of poor survival rates of patients with pharyngoesophageal malignancies, the optimal
reconstructive procedure would have one stage, a low complication rate, and a brief hospitalization and
would allow an adequate resection of the neoplasm with an acceptable operative mortality. The need for
obligate stoma formation should be eliminated. Not only should airway patency be preserved and deglutition
be restored early, but these functions would hopefully be retained as long as possible with recurrent
disease. Donor tissue should be from beyond the field of preoperative radiotherapy and relatively resistant
to harm from postoperative irradiation. Reconstruction would be facilitated by mucosa-bearing tissue and as
little violation of body cavities as possible.
Multiple other methods of pharyngoesophageal reconstruction exist, each having its own merits.
Disadvantages of these techniques variably include the need for multiple stages and prolonged
recuperation, limitations by extent of neck dissection or perioperative radiation, fistula formation,
pharyngostomes, stricture formation, multiple gastrointestinal suture lines, violation of multiple body cavities,
and the requirement of advanced or highly specialized surgical techniques.
FLAP DESIGN AND DIMENSIONS
While approximation of resection margins is usually possible in the hypopharynx and upper esophagus,
excessive tension all too often results in stricture, fistula, or limitation of tongue mobility. Local mucosal flaps are
often satisfactory for small or less than circumferential defects. Regional unipedicled cervical flaps (17) provide a
logical, regional, albeit multistage, means of reconstruction. The Wookey flap (18) is also limited by the extent of
previous neck dissection and radiation and requires the presence of a pharyngostome and an esophagostome.
The medially based deltopectoral flaps (19) employ tissue with a known arterial supply from beyond irradiated or
dissected cervical tissue to restore upper aerodigestive continuity. This procedure also requires the interim use
of stomata and typically requires two or more stages. Reversed split-thickness skin grafts supported by tantalum
or steel mesh (20, 21) have been used, but they frequently result in stricture formation or mesh migration and
erosion.
In the fortuitous event that the anterior upper half of the trachea and larynx is spared from tumor, this tissue may
be used to reconstitute the anterior esophageal wall (22, 23). It has been noted that split-thickness skin grafts
may be used for recreation of the posterior pharyngeal wall if necessary. While providing a conservative means
of reconstructing the hypopharynx in a single-stage procedure, this technique is limited by the restrictions it
places on margins of resection, as well as postoperative stricture formation.
The pectoralis major musculocutaneous flap also has been used to fashion into a pharyngoesophagus (24).

While using one procedure to bring healthy tissue into the neck, it may be rather bulky when tubed and it lacks
mucosal lining and peristalsis.
The gastrointestinal tract is often employed as a donor for pedicled or free grafts. Gastric, small bowel, or colonic
transpositions provide one-stage reconstruction. A long suture line (25) has been applied to a strip of
vascularized reversed greater curvature to form a pedicled gastric tube for similar application. These technically
challenging procedures develop a segment of bowel on a long pedicle and invade the abdominal or pleural
cavity, mediastinum, or chest wall. There are multiple potential gastrointestinal, thoracic, or mediastinal
complications that often relate to breakdown of suture lines. Pedicled techniques all too often lead to excessive
tension on the superior suture line.
Free transfer of revascularized intestine allows for a standardized approach to difficult problems of upper
aerodigestive reconstruction with little regard for size or configuration of the surgical defects. Extirpative
procedures may extend from the base of the skull to the mediastinum, and reliable reconstruction is possible with
viable mucosa-bearing tissue with relatively few contraindications. Extensive atherosclerosis and radiation injury
are only relative contraindications, since extension of the vascular pedicle with vein grafts allows for selection of
more suitable recipient vessels. The surgeon's lack of familiarity with microsurgical technique is the prime
contraindication to performance of such a free transfer.
OPERATIVE TECHNIQUE
Donor Site
Once the extent of resection and the needs of the recipient site have become apparent, a second team may
begin the search for an intestinal segment suitable for transfer. This is usually done through a left upper
quadrant transverse incision. After locating the ligament of Treitz, the caliber and the vascular pedicle and
arcade are inspected to select an acceptable segment of bowel, typically 10 to 14 cm in length. The
requirements of the recipient site are usually met by a segment from the proximal jejunum.

FIGURE 225.1 A: Pharyngoesophageal defect after tumor extirpation. Intestinal segment may be anastomosed
to base of tongue if necessary. B: Intestinal segment should be mobilized on as long a pedicle as possible.
Mesenteric vessels are divided only when recipient vessels and pharyngoesophageal margins have been fully
exposed and prepared for anastomosis. C: Critical proximal anastomosis is completed, with optimum
visualization first, allowing the intestinal segment to be suspended prior to revascularization. D: Interrupted
sutures of distal anastomosis have been placed after completion of proximal intestinal and microvascular
anastomoses. E: A small silicone window is incorporated into the suture line, allowing for observation of
transferred segment postoperatively.
Recipient Site
Once the segment is isolated on its pedicle, the bowel margins are divided and observed for satisfactory
bleeding and, hence, viability. While the abdominal team is developing this segment on as long a pedicle as
possible, the presumptive recipient vessels may be prepared for anastomosis if their caliber matches the donor
vessels appropriately. Branches of the external carotid artery and tributaries of the external jugular vein usually
have the most suitable caliber and location. The superior thyroid artery is often selected, since the inferior
thyroid, cervical, and intrathoracic vessels often lie too low to receive the free intestinal transfer. Occasionally,
contralateral vessels are chosen for anastomosis when preoperative radiotherapy has been administered

ipsilaterally. If necessary, any larger vessel, including the carotid itself, may be employed for a side-to-end
anastomosis with the donor vessel.
Once the recipient vessel in the neck is prepared and flow is confirmed, the intestine may be harvested. If the
bowel needs to be elongated, division of the mesentery at the second level of arcades may help to some extent
(26). As the mesenteric donor vessels are being microscopically prepared by one team, the abdomen is
simultaneously closed following a bowel anastomosis. Consideration is also given to the performance of a
gastrostomy.
The isolated segment is brought to the neck, preferably iso-peristaltically, and a proximal anastomosis is
performed to the pharyngeal margin. Thus, difficult proximal anastomotic sutures may be placed accurately and
the free intestine suspended and secured from motion during the microsurgical portion of the procedure. The
veins are anastomosed first. Once both anastomoses are complete, the clamps are released in the same order.
Obvious pulsation of mesenteric vessels, peristalsis, production of secretions, and vigorous bleeding from the
non-anastomosed bowel margin should be evident. If discrepancies exist between the caliber of the recipient and
donor tissues, antimesenteric incisions in the donor bowel will assist in a proper match.
Before completion of the distal anastomosis, a nasogastric tube may be threaded through the lumen of the
neoesophagus. Inclusion of a small silicone window in the neck closure allows for direct observation of flap
viability (Fig. 225.1E). Some forego this direct observation and perform regular postoperative endoscopy instead
(27) (Fig. 225.2).
Although cooling of the isolated bowel prior to transfer has been advocated (28), bowel ischemia time has been
reduced to 60 to 90 minutes in the Emory series by awaiting complete preparation of the recipient site and
vessels as a prerequisite to transecting the mesenteric pedicle. Similarly, the two-team approach allows for
completion of transfer within 1½ to 2 hours following excision. Low-molecular-weight dextran and steroids were
administered in the Emory series, while heparinization is used in some centers (27). As a rule, oral liquids may be
taken by the patient several days postoperatively. Care must be taken throughout the postoperative course to
avoid flap constriction by tracheostomy tube tapes or dressings.
CLINICAL RESULTS
After this single-stage reconstruction, the average patient in the Emory series could swallow at 12 days
postoperatively. Twenty-eight of 32 patients were hospitalized less than 21 days following their procedure.
Consequently, there was no significant delay in initiating postoperative radiotherapy. Two of 25 patients
who underwent this procedure following resection of tumor suffered non-tumor-related stricture formation;
four patients developed dysphagia secondary to tumor recurrence. There was no incidence of stenosis
following repair of seven preexisting strictures (29).
The intestinal segment used in most cases has been jejunum; however, advantages of colon as an
autotransplant should not be overlooked. These include compatibility of the larger lumen with needs of
nasopharyngeal construction, smaller amount of bowel secretions and regurgitation, and the larger vascular
pedicle.

FIGURE 225.2 A barium swallow should be obtained several days postoperatively prior to resumption of
oral intake. (From McConnel et al., ref. 15, with permission.)
A gradual return of basal electrical activity has been documented in autotransplanted bowel both
experimentally and clinically. Furthermore, the return of good swallowing ability, weight gain, and normal
distal esophageal function, correlating with absence of reflux symptoms, have been documented in patients
after jejunal transfer (26). Contraction of these grafts in response to either local or gastric antral distension
is indicative of retention of intrinsic myoelectric activity, as well as some neurohumoral feedback mechanism
(26).
By 1982, more than 100 cases of free intestinal transfer had been reported in the literature, with a
cumulative mortality rate of 5.4%. Most of these deaths were from cardiorespiratory causes, as late as 5
weeks postoperatively. Twelve percent of patients suffered major complications, most related to necrosis or
infection of the autograft. Half the major complications are now preventable with improvements in venous
microanastomosis and vigilant pulmonary care to prevent aspiration pneumonia that arises from graft
secretions in the early postoperative period. There was an 11% minor complication rate. These consisted
primarily of transient fistulas and three patients who experienced occasional self-limiting dysphagia.
SUMMARY
Free vascularized bowel transfer in the hands of experienced microsurgeons has become a reliable,
versatile, and rapid method of restoring pharyngeal or esophageal integrity with functional mucosa-bearing
tissue. Although an abdominal procedure is necessary, the dissection is far from extensive, with addition of
an intraabdominal anastomosis.
References
1. Longmire WP Jr. A modification of the Roux technique for antethoracic esophageal reconstruction:
anastomosis of the mesenteric and internal mammary blood vessels. Surgery 1947;22:44.

2. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by
a revascularized isolated jejunal segment. Ann Surg 1959;149:162.
3. Hiebert AC, Cummings GO. Successful replacement of the cervical esophagus by transplantation and
revascularization of a free graft of gastric antrum. Ann Surg 1961;154:103.
4. Roberts RE, Douglass FM. Replacement of the cervical esophagus and hypopharynx by a revascularized
free jejunal autograft. N Engl J Med 1961;264:342.
5. Nakayama K, Yamamoto K, Tamiya T, et al. Experience with free autografts of the bowel with a new
venous anastomosis apparatus. Surgery 1964; 55:796.
6. Jurkiewicz MJ. Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast
Reconstr Surg 1965;36:509.
7. Peters CR, McKee DM, Berry BE. Pharyngoesophageal reconstruction with revascularized jejunal
transplants. Am J Surg 1971;121:675.
8. Mullens JE, Pezacki ZJ. Reconstruction of the cervical esophagus by revascularized autografts of
intestine. Int Surg 1971;55:157.
9. Uemichi A, Invi K, Onchi K, et al. Reconstruction of the cervical esophagus by transplantation and
revascularization of small intestinal segment: ten year follow-up. Surgery 1977;81:343.
10. McKee DM, Peters CR. Reconstruction of the hypopharynx and cervical esophagus with microvascular
jejunal transplant. Clin Plast Surg 1978; 5:305.
11. Chang TS, Hwang OL, Wang-Wei. Reconstruction of esophageal defects with microsurgically
revascularized jejunal segments: a report of 13 cases. J Microsurg 1980;2:83.
12. Hester TR, McConnel FM, Nahai F, et al. Reconstruction of cervical esophagus, hypopharynx and oral
cavity using free jejunal transfer. Am J Surg 1980;140:487.
13. Sasaki T, Baker HW, McConnell DB, Vetto RM. Free jejunal graft reconstruction after extensive head and
neck surgery. Am J Surg 1980; 139:650.
14. Oesch I, Helikson MA, Shermeta DW, et al. Esophageal reconstruction with free jejunal grafts: an
experimental study. J Pediatr Surg 1980;15:433.
15. McConnel FMS, Hester TR, Nahai F, et al. Free jejunal grafts for reconstruction of pharynx and cervical
esophagus. Arch Otolaryngol 1981;107:476.
16. Harashina T, Kakegawa T, Imai T, Suguro Y. Secondary reconstruction of oesophagus with free
revascularized ileal transfer. Br J Plast Surg 1981;34:17.

17. Trotter W. Operative treatment of malignant disease of the mouth and pharynx. Lancet 1913;1:1075.
18. Wookey H. The surgical treatment of carcinoma of the pharynx and upper esophagus. Surg Gynecol
Obstet 1942;75:499.
19. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction of the cervical esophagus
and pharynx. Plast Reconstr Surg 1965;36:509.
20. Negus VE. Reconstruction of pharynx after pharyngoesophagolaryngectomy. Br J Plast Surg 1953;6:99.
21. Edgerton MT. One-stage reconstruction of the cervical esophagus or trachea. Surgery 1952;31:23.
22. Asherson N. Pharyngectomy for post-cricoid carcinoma: one-stage operation with reconstruction of the
pharynx using the larynx as an autograft. J Laryngol 1954;68:550.
23. Som ML. Laryngoesophagectomy: primary closure with laryngotracheal autograft. Arch Otolaryngol
1956;63:474.
24. Withers EH, Franklin JD, Madden JJ, Lynch JB. Immediate reconstruction of the pharynx and cervical
esophagus with the pectoralis major myocutaneous flap following laryngopharyngectomy. Plast Reconstr
Surg 1981;68:898.
25. Heimlich HJ. Reconstruction of the esophagus with a reversed gastric tube. Surg Gynecol Obstet
1962;114:673.
26. Meyers WC, Seigler HF, Hanks JB, et al. Postoperative function of free jejunal transplants for
replacement of the cervical esophagus. Ann Surg 1980;192:439.
27. Ancona E. Gastrointestinal microsurgery: colonic and jejunal autotransplants for cervical esophagoplasty.
Int Surg 1981;66:39.
28. Flynn MB, Acland RD. Free intestinal autografts for reconstruction following
pharyngolaryngoesophagectomy. Surg Gynecol Obstet 1979;149:858.
29. Hester TR. Personal communication, 1982.

Chapter 226
Jejunal Free Flap
J. J. COLEMAN III
EDITORIAL COMMENT
The jejunal free flap for esophageal reconstruction is an elegant and attractive technique; however, it is not
clear if swallowing or voice restoration with a Blom-Singer valve is any better with this flap than with a tubed
flap such as the radial forearm.
The jejunal free flap or jejunal free autograft is a reliable, frequently used method of transferring a segment of
bowel to replace an area lined with mucosa. Because of the length of the small bowel, its constant blood supply,
and its more favorable bacterial content, the jejunum has been more popular than segments of the colon or
stomach. The size of the jejunal branches of the mesenteric vessels allows revascularization at the site of
reconstruction with microscope or loupe magnification.
INDICATIONS
Although usually used to reconstruct circumferential defects of the laryngopharynx, this flap is also useful in
reconstruction of partial pharyngeal defects, oral cavity, and vagina. The defect created by extirpation of
malignancy in the upper aerodigestive tract is characterized by heavy bacterial contamination, possible
previous radiotherapy, and complex functional significance. Because late-stage disease requiring such
surgery has a high likelihood of early recurrence, single-stage restoration of function and reasonably normal
appearance are crucial.
The predominant functions of the upper aerodigestive tract are alimentation and respiration; more
specialized actions include swallowing and speech. Although the precise recreation of speech has been
elusive, swallowing is facilitated by providing a patent conduit between the oral cavity and the remaining
esophagus. Jejunum is of a similar caliber and structure to the cervical esophagus and pharynx and is thus
useful for replacement of total laryngopharyngectomy defects from the nasopharynx at the base of the skull
to the thoracic inlet, or occasionally to the aortic arch. It is most useful when the larynx has been removed
because its copious secretions may result in aspiration with the larynx in place.
Using the jejunum as a tube-fillet combination, the total or partial glossectomy/laryngectomy defect can be
reconstructed with a single segment of bowel (Fig. 226.1). Partial defects of the hypopharynx, oropharynx,
and oral cavity are also amenable to reconstruction using a patch of jejunum, again best suited in the
absence of the larynx. The length of the mesentery of the jejunum and the need for midline position of the
bowel require recipient vessels in the neck. If previous radical neck dissection or vascular disease result in
deficient vessels, a flap with a longer pedicle, such as the gastroepiploic flap or the radial forearm flap, may
be necessary to reach branches of the axillary artery. The presence of ascites is a contraindication to this
procedure.
Although the jejunum is expendable and useful as both a circumferential and patch repair, other methods
are also available (1). When the larynx remains intact, the jejunum should not be used unless the segment
is at or below the cricopharyngeus. For patch-type defects or when the larynx is intact, the lateral arm,
radial forearm, scapula, and lateral thigh flaps all provide epithelial lining to replace pharyngeal mucosa,

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with minimal to moderate donor-site morbidity. Circumferential
defects can be closed with the larger skin flaps of the radial forearm and scapula.
FIGURE 226.1 By splitting the jejunum along its antimesenteric border, a combination tube-fillet
configuration can be obtained that will allow reconstruction of defects that have both circumferential and
planar components. The pliability of the planar area allows it to conform to the shape of the buccoalveolar
mucosa pharyngeal wall or the floor of mouth area.
FIGURE 226.2 The pattern of blood supply to the small intestine changes from proximal to distal. In the
jejunum, there is usually only one arcade before the vasa recta directly supplying the mesenteric border of
the bowel. In the ileum, there are multiple arcades between the main ileal branch and the vasa recta,
making determination of the segment of bowel perfused by a single branch more difficult.

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ANATOMY
The jejunum is the second portion of the small intestine, beginning at the ligament of Treitz and extending
approximately 8 feet distally. The blood supply includes the jejunal branches of the superior mesenteric artery
and vein that pass through the mesentery and arborize to supply the gut. In the proximal mesentery, there is
usually only one arcade of vessels distal to the segmental artery and vein, with the vasa recta extending directly
off the arcade. This makes the relationship between the branch of the superior mesenteric artery and the
segment of gut it supplies more direct than in the ileum, where there are two or three arcades of vessels between
the superior mesenteric artery and vein and the vasa recta to the bowel (Fig. 226.2). When harvested, the
diameter of the jejunal vessels from the superior mesenteric artery and vein range from 2 to 4 mm.
FLAP DESIGN AND DIMENSIONS
To some degree, the segment of jejunum available on a single pedicle depends on body habitus and the length
of the mesentery. The selection of an appropriate branch and its subsequent blood supply can result in lengths
of bowel from 10 to 30 cm. The mesentery of the small bowel varies with body habitus but generally ranges in
length from 15 to 20 cm.
Selection of appropriate vessels in the neck before harvesting the jejunal free autograft is of paramount
importance. The ischemia tolerance of jejunum is low, requiring revascularization in 2 hours or less. Because the
ideal location for the bowel conduit is in the midline (the anatomic site of the pharynx and cervical esophagus),
and because there is an obligate length of mesentery necessary before anastomosis can be done, vessels
situated in the lateral neck are best for recipients.
OPERATIVE TECHNIQUE
The transverse cervical vessels can be found just lateral to the jugular vein deep to the omohyoid in the medial
posterior triangle; these are ideal for anastomosis low in the neck. The facial and occipital branches of the
external carotid, which lie just beneath the digastric muscle on the lateral neck and external jugular vein, may be
dissected out and placed laterally in the superior neck (Fig. 226.3). Anastomosis to the main internal jugular or
the proximal medial branches of the external carotid requires bowing of the jejunum off the midline or
folding of the mesentery. The former impairs subsequent transit of food through the conduit, and the latter
increases the risk of venous thrombosis. Whatever vessels are chosen should be completely prepared for
micosurgical anastomosis before division of the jejunal vessels.
FIGURE 226.3 The omohyoid and digastric muscles are excellent landmarks for vessel selection in the neck.

Beneath the omohyoid in the posterior triangle lie the transverse cervical vessels, which usually arise from the
thyrocervical trunk of the subclavian artery. These vessels are frequently present even after neck dissection and
may even be enlarged as collateral blood supply to the neck. Division of the branches to the scalene muscles
and levator scapulae provide an excellent vascular pedicle. Dissection along the posterior belly of the digastric
muscle reveals the occipital and facial branches of the external carotid artery, which can be transposed either
medially or laterally for vascular anastomosis. The external jugular vein is a satisfactory recipient vessel and
should be preserved whenever possible in the initial exposure of the neck.
A supraumbilical midline incision is used to enter the abdomen. After identifying the ligament of Treitz, the
jejunum is mobilized to a point that will easily allow the tube jejunostomy to be affixed to the abdominal wall after
harvest of the segment of jejunum. Once this general area has been identified, the mesentery is examined (using
transillumination, if helpful) to identify a jejunal branch of the mesenteric vessels and follow its arborization
distally and to provide a segment of jejunum adequate to cover the defect. Usually, a slightly longer segment is
identified and trimmed back later in the neck. The proximal and distal ends of this segment are marked to orient
the bowel in an isoperistaltic direction.
The mesentery is incised in a triangle, the apex of which is at the origin of the jejunal branch of the superior
mesenteric vessels, and the mesentery and vessel branches are divided and ligated, taking care to observe their
branching and to avoid injuring vessels that supply the segment. The bowel is divided at its proximal and distal
ends with a GIA stapler. At this point, the ends of the divided bowel are observed for several minutes to ensure
adequate vascular supply at the sites of future anastomosis. If the bowel is dusky at this point, this indicates
injury to its blood supply and requires resection back to viable vascularized tissue (Fig. 226.4). An end-to-end or
end-to-side jejunojejunostomy is performed between the proximal and distal segments and the mesentery repair,
leaving the separated segment supplied by its own blood vessels.
FIGURE 226.4 Transection and ligation of the mesentery may result in ischemia to the bowel to be harvested or
to the proximal and distal bowel. Because the intraenteric collateral blood supply is limited to about 2 cm, it is
important to observe the ends of the segments carefully before performing reanastomosis or harvest of the
segment. Any ischemic-appearing bowel should be resected by ligating directly along the mesenteric border.

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Distal to the jejunojejunostomy, a Witzel tube jejunostomy is placed, brought through the abdominal wall, and the
serosa around the tube fixed to the peritoneum (Fig. 226.5). With bowel continuity reestablished, the abdomen is
irrigated, and the segment of bowel is left in situ until it is ready to be harvested for the reconstruction. Before
removing the segment, careful dissection of the base of the mesentery is important to provide maximal pedicle
length and to avoid injury to the pedicle or to the superior mesenteric vessels. Meticulous cleaning of fat and
lymphatic tissue and individual ligation of the artery and vein decrease the ischemia time for the segment in the
neck and minimize the chance of intraabdominal bleeding. As soon as the segment is transferred to the
reconstructive team in the neck, the abdominal wall is closed.
Of utmost importance in successful reconstruction and avoidance of fistula, is visualization of the
pharyngoenteric anastomosis site, so that precise suturing can be performed. Most often, the proximal
anastomosis is more difficult to visualize, particularly when the tumor has extended cephalad into the
nasopharynx. Mandibulotomy or other adjunct procedures may be necessary to afford adequate visualization; it
should be performed before division of the jejunal vascular branches in the abdomen.
When the jejunum has been situated in a comfortable position in the neck, the most difficult bowel anastomosis is
performed using 3-0 absorbable suture in two layers, when
possible incorporating seromuscular and musculomucosal sutures. Sometimes single-layer full-thickness sutures
are preferable. The most difficult areas to visualize are the lateral aspects of a high circumferential suture line.
Placement of several seromuscular sutures from the bowel wall to the prevertebral fascia (Fig. 226.6) will help
suspend the segment and avoid traction on the sutures of the proximal anastomosis.
FIGURE 226.5 Reanastomosis of the bowel is performed and the mesentery approximated. A tube jejunostomy is
placed distal to the enteric anastomosis, and the bowel is affixed to the parietal peritoneum and abdominal wall.
The segment of bowel to be used for reconstruction can be left in situ until the time for revascularization in the
neck. Careful dissection of fat and lymphatic tissue off the base of the mesentery will allow the best exposure for
ligation and division of the jejunal vessels.
The mesentery is tacked to the neck to keep it from folding on turning of the neck, and microvascular
anastomosis is performed. As previously stated, it is imperative that the recipient vessels lie in a position in which
they will not kink, the mesentery will not kink, and the bowel segment can remain in the midline. At this point, if
there is some question that the ischemia time may exceed 2 hours, the arterial anastomosis should be performed

first. Revascularization of the segment produces vigorous contraction of the bowel and mucorrhea.
Careful reassessment then should be made of the length of bowel necessary to close the defect. The segment
should be straight and under slight tension when both visceral anastomoses have been completed, as there is a
tendency for elongation of the segment over time, and thus interference with passage of the food bolus. Excess
bowel should be removed right along the mesenteric border to avoid damage to the blood supply in the more
proximal mesentery. Excess mesentery can be used to reinforce the suture line or to help close a neck wound
where skin has been resected. Because stricture may occur at the distal anastomotic line, triangular
interdigitation of the jejunum into the esophagus is useful. In cases where the lesion is low and the resection may
extend into the thoracic esophagus, the distal enteric anastomosis should be performed first, because it is likely
to be the most difficult. The jejunal esophageal anastomosis is performed in two layers, taking care not to narrow
the lumen.
FIGURE 226.6 As much of the pharyngoenteric anastomosis as possible should be done in two layers.
Spatulation of the esophagus will help prevent stenosis at the distal suture line. Fixation of the segment to the
rigid prevertebral fascia will help relieve tension on the proximal anastomosis and perhaps decrease fistula
formation. Any excess length of jejunum should be trimmed so that the conduit is straight between the pharynx
and the esophagus.
Occasionally, there is a size mismatch between the proximal jejunum and the proximal oropharyngeal defect. A
wider anastomosis can be obtained by creating an end-to-side anastomosis. The jejunum is opened along its
antimesenteric border to the appropriate length and then sutured to the base of the tongue and pharynx (Fig.
226.7).
All positioning of the bowel segment and vessels, both donor and recipient, should be done with recognition that
the neck at the time of microvascular anastomosis is frequently hyperextended and turned to its most lateral
extent. The vascular anastomosis must be situated well in all positions—neutral, flexion, and contralateral
rotation—to avoid vascular compromise.
There are numerous methods of monitoring the vascular integrity of the jejunal free autograft. We prefer the

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combination of Doppler ultrasound and direct observation. A short segment of the skin suture line is left open
over the serosa of the bowel and packed with xeroform gauze; it can be visualized
for monitoring and for direct Doppler ultrasound evaluation (Fig. 226.8). In addition to this, a line is marked on the
skin over the site of the anastomosis and along the course of the mesenteric vessels. Hourly Doppler ultrasound
checks are performed. After several days, the xeroform gauze is removed, and the defect is closed secondarily or
allowed to contract.
FIGURE 226.7 A wider pharyngojejunal anastomosis is sometimes necessary when the defect includes the base
of the tongue. With the proximal bowel oversewn, enterotomy along the antimesenteric border can provide an
opening of variable length for end-to-side anastomosis.
CLINICAL RESULTS
Measurement of success in pharyngeal reconstruction evaluates the restoration of ability to provide
nourishment adequate to maintain weight perorally. Several large series have shown an 80% to 83%
success rate in meeting this goal, using the jejunum as reconstruction for pharyngeal defects (2, 3). Viability
of the jejunal graft was achieved in 95% to 97% of patients (2, 3). Several smaller series have corroborated
these results. Jejunum transfer thus has been demonstrated to be a reliable method for pharyngeal
reconstruction. Complications have been frequent in the neck, but more than 50% of cases resolve without
surgical intervention (4). Despite the comorbidities carried by many of the patients, abdominal and
pulmonary complications have been low and mortality in the range of 3% to 5% compared with 10% to 25%
for gastric pull-up (5).

FIGURE 226.8 Monitoring may be performed by a combination of direct observation of the serosa through a
small opening in the suture line and Doppler ultrasound. Marking the skin over the jejunal vessel path to the
bowel will help localize the vessel itself and avoid confusion with the carotid and its branches.
Voice restoration, another desirable reconstructive goal, can be achieved by immediate or delayed
tracheoesophageal puncture through the jejunal segment. The unpredictable contraction of the jejunum
may impede the flow of air from the stomach to the mouth, however, and a more flaccid radial forearm free
flap may provide superior voice reconstruction (6).
SUMMARY
The jejunal free autograft is an effective, reliable method of reconstructing total or partial pharyngeal
defects. Defects of variable length and shape may be addressed with high likelihood of graft viability and
functional restoration.
References
1. Coleman JJ. Reconstruction of the pharynx and cervical esophagus. Surg Rounds 1991;14:855.
2. Coleman JJ, Searles JM, Hester TR, et al. Ten years experience with the free jejunal autograft. Am J Surg
1987;154:394.
3. Reece GP, Schusterman MA, Miller MJ, et al. Morbidity and functional outcome of free jejunal transfer
reconstruction for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg
1995;96:1307.
4. Coleman JJ, Tan KC, Searles JM, et al. Jejunal free autograft: analysis of complications and their
resolution. Plast Reconstr Surg 1989;84:589.
5. Surkin ME, Lawson W, Biller H. Analysis of the methods of pharyngoesophageal reconstruction. Head
Neck Surg 1984;6:953.
6. Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed radial forearm
flap. Clin Plast Surg 1994;21:137.

(Trang không có chữ)

Chapter 227
Microvascular Free Transfer of A Compound Flap of Stomach and
Omentum
J. BAUDET
B. PANCONI
L. VIDAL
EDITORIAL COMMENT
When the omentum has been used and there is no other cutaneous cover, most surgeons will use an
immediate skin graft, in contrast to leaving it exposed for 10 days, as the authors indicate.
Despite the theoretical advantages of musculocutaneous flaps, many complications are still encountered. This is
why another technical procedure is often necessary in special cases, namely, the free transfer of greater
omentum and stomach (1, 2).
INDICATIONS
The merit of this procedure is to allow a one-stage reconstruction that closes large pharyngoesophageal
defects with particularly well vascularized tissue. Despite some difficulties, it is a safe and reliable
procedure. Anastomoses are located away from the recipient site in the axillary area where vessels run
deep, and the donor site has not been irradiated and is usually free of major atherosclerotic processes.
Also, the reconstruction is functional. Obviously, the procedure should not replace well-known simpler
methods (local skin flaps, distant cutaneous or musculocutaneous flaps) that are recommended whenever
possible. Furthermore, free flaps to the oral cavity, even with moderately irradiated tissues and vessels (3),
have their own indications, as do free transfers of gastrointestinal tissue of other types, such as jejunum (4,
5, 6, 7) (see Chapter 225), sigmoid (8, 9, 10, 11, 12), and gastric antrum (13).
The compound stomach-omentum flap should be selectively used with the following indications: for closure
of inveterate pharyngostoma in heavily irradiated tissue, most likely after several unsuccessful previous
attempts at closure by other methods; for closure of long-standing partial or subtotal defects of the cervical
esophagus under unfavorable local conditions; and for primary reconstruction of large defects of the
pharyngeal wall.
The portion of stomach included in the transfer has an excellent blood supply and provides an especially
good solution for reconstruction of any partial and subtotal defect of pharyngeal or esophageal wall. The
greater omentum, thanks to its own rich blood supply, also is known for its properties of defense against
infection, its ability to participate in biologic debridement, its potential for adapting its shape to any anatomic
contour, and its ability to granulate, thus offering an excellent bed for skin grafting. Apart from general
contraindications, such as diabetes, severe atherosclerosis, malnutrition, and anemia, this procedure is also
not feasible in patients who have had past gastric surgery such as gastrectomy or gastrostomy.
ANATOMY
The greater curvature of the stomach receives its blood supply from short vessels emerging from the right and

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left gastroepiploic vessels. The right gastroepiploic pedicle is predominant from both anatomic and dynamic
viewpoints (14). This pedicle is constant, and the artery and vein have large diameters. The most appropriate
part of the greater curvature of the stomach to be included in continuity with the omentum must be located as
distally as possible from the origin of the right gastroepiploic pedicle in order to obtain the longest pedicle (Fig.
227.1). Finally, the whole greater omentum, depending on the vascular territory of the right gastroepiploic
pedicle, must be freed and included in the transfer.
FLAP DESIGN AND DIMENSIONS
The considerable length of the pedicle (about 30 cm) allows vascular anastomoses to be located at a suitable
distance from the cervical area, where postoperative or postradiotherapeutic sclerosis precludes reasonable
chances for another type of transfer (Fig. 227.2). These anastomoses are located in the axillary area. The
dimensions of the largest flap available are about 13 cm long and 8 cm wide.
FIGURE 227.1 Schematic diagram of the compound free transfer of omentum and stomach based on the right
gastroepiploic pedicle.
OPERATIVE TECHNIQUE
Donor Site
The right gastroepiploic artery and vein are identified and exposed through a median abdominal incision located
above the umbilicus. The greater omentum is then progressively freed from the transverse colon and mesocolon
and subsequently, from right to left, from the stomach through a complete ligation of the short gastric vessels.
The stomach is clamped level with the great curvature, and the gastric flap is excised in continuity with the
greater omentum, preserving the short gastric vessels that supply the flap at this level. Bleeding from the gastric
wall is then checked, and the right gastroepiploic pedicle is severed. The transfer is immersed in a chilled
heparinized serum (15,000 U intravenously per 100 cc) and any remaining blood is squeezed out by gentle finger
manipulation.
The stomach is finally closed over a suction nasogastric tube in two layers with deep interrupted extramucosal
stitches and running superficial sutures. Removal of this gastric flap produces narrowing of the lumen in the
midsection of the stomach that is reduced to 2.5 cm in diameter but without functional consequences (2, 15).

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FIGURE 227.2 Schematic diagram of the axillary area showing anastomoses of the right gastroepiploic pedicle
with the subscapular pedicle.
Recipient Site
The axillary artery and vein are identified, and further dissection provides adequate exposure of the origin and
course of the subscapular artery and vein.
Revascularization of the transfer is carried out by end-to-end anastomoses of the right gastroepiploic artery (2.5
mm) to the subscapular artery and the right gastroepiploic vein to the subscapular vein (3 mm) (see Fig. 227.2).
After release of the arterial clamp, the quality of the revascularization of the gastric wall section is observed, as
well as pulsation of the gastroepiploic vessels.
The skin of the left anterior chest wall is then widely undermined from the axilla to the neck. The long transfer
then is brought through this spacious tunnel to the recipient site, adequately prepared by a large excision of
pharyngeal or esophageal wall and any necrotic, infected, or scarred tissue (Fig. 227.3). The anterior pharyngeal
and/or esophageal wall is then reconstructed by suturing of the gastric flap using one layer
of full-thickness 3-0 absorbable interrupted sutures, and this is covered by several layers of folded over omentum
extending laterally past the suture line of the gastric flap to obtain a thick padding and efficient packing of any
early postoperative fistula.