Richard E. Hayden, MD; Michael L. Hinni, MD Department of … · 2013. 9. 29. · RE. Oncologic...

© 2013 Mayo Foundation for Medical Education and Research

Courtney M. Tomblinson, MD; S. Santino Cervantes, MD; April M. Landry, MD;

Richard E. Hayden, MD; Michael L. Hinni, MD

Department of Otolaryngology - Head and Neck Surgery – Mayo Clinic Hospital - Phoenix, Arizona

• The tubed submental flap is an additional

neopharyngeal reconstructive option for

patients with total laryngopharyngectomy.

• Large defects can be repaired in a single-

stage operation, reliably and rapidly.

• Donor site morbidity is low, as the tubed

submental flap is harvested from the same

surgical wound and does not require a

second surgical team nor microvascular

reconstruction

Conclusions

1. Howard BE, Nagel TH, Donald CB, Hinni ML, Hayden

RE. Oncologic safety of the submental flap for

reconstruction in oral cavity malignancies. Otolaryngol

Head Neck Surg 2013;149:40 .

2. Wang WH, Hwang TZ, Chang CH, Lin YC.

Reconstruction of pharyngeal defects with a submental

island flap after hypopharyngeal carcinoma ablation.

ORL 2012;74:304-309.

3. Patel UA, Bayles SW, Hayden RE. The submental flap:

a modified technique for resident training. Laryngoscope

2007;117:186-189.

4. Chu PY, Chang SY. Reconstruction after resection of

hypopharyngeal carcinoma: comparison of the

postoperative complications and oncologic results of

different methods. Head & Neck. 2005;27(10):901-8

5. Espitalier F et al. Results after U-shaped pectoralis

major myocutaneous flap reconstruction of

circumferential pharyngeal defects. Laryngoscope

2012;122:2677-2682

6. Lopez F et al. Outcomes following

pharyngolaryngectomy with fasciocutaneous free flap

reconstruction and salivary bypass tube. Laryngoscope

2012;123:591-596.

References

Discussion

Patients requiring total, circumferential laryngo-

pharyngectomy had limited options for reconstruction in

the past. These options include pectoralis major

myocutaneous flap, anterolateral thigh free flap, and free

jejunal interposition grafts. Significant morbidity is

associated with these reconstructions.

We submit a novel technique for circumferential total

laryngopharyngectomy reconstruction using a tubed

myocutaneous submental pedicled flap that decreases

morbidity and has acceptable functional outcome. To our

knowledge, this is the first successful application of this

technique. Previous studies report its use with partial

defects.

Technique

The pedicle of our submental flap consisted of venous drainage by the external jugular vein and was arterially based on the the submental artery, a branch of the facial artery. The skin paddle, measuring 15 cm in length by 8 cm in width, was carefully elevated, beginning with the superior incision, dissecting to the inferior border of the mandible to avoid cutaneous perforating vessels and releasing the mylohyoid muscle down.

The lesion, shown in Figure 2, crossed midline posteriorly and only a thin, 1 cm strip of pharyngeal mucosa could be salvaged. This was excised to prevent a second vertical anastamosis, completing the total laryngopharyngectomy. An 8cm defect remained between the native pharynx and the cervical esophagus.

The submental flap was rotated inferiorly, formed into a tube with the squamous epithelium lining the inner surface of the tube. The superior and inferior anastamoses were sutured closed. A nasogastric tube was placed to serve as a conduit. The final anastamosis was zippered shut from superior to inferior over the nasogastric tube.

The mylohyoid and digastric muscles were incorporated into the flap so as to add extra bulk on the superficial portion of the neopharyngeal reconstruction once tubed. After a left selective neck dissecion of levels II-V, the stoma was matured and the neck was closed primarily without extraneous tissue or grafting.

Introduction

82 year old male with a six-month history of non-

productive cough and odynophagia and a previously

resected and irradiated T1 right glottic tumor. Endoscopic

examination revealed a left piriform sinus lesion with

apparent involvement of the left cricoarytenoid joint and

immobility of the left true vocal cord. PET scan revealed

avidity in the left side of the larynx and hypopharynx.

The tumor was visualized via direct laryngoscopy and

esophagoscopy, spanning from the left piriform sinus onto

the left arytenoid and extending into the party wall. The

burden was too extensive to be performed via an

endoscopic approach and the patient underwent total

laryngopharyngectomy, left selective neck dissection, and

neopharyngeal reconstruction with a myocutaneous

submental pedicled flap. A nasogastric feeding tube was

placed to serve as a conduit for the newly formed tubed

neopharynx.

A PEG tube was placed and tube feeds were started 24

hours later. The nasogastric tube conduit was removed

prior to discharge. The patient began an oral diet on POD

17. He did not experience any localized infection and no

evidence of leak.

He completed adjuvant radiation three months post-

operatively and has experienced dysphagia since

radiation. Exam at his last visit reveals a mildly stenotic

inlet at the superior anastamosis and a second stenosis

at the inferior anastamotic suture line of the neopharynx.

He underwent esophageal dilation with significant

improvement in the neopharyngeal lumen.

Case Report

Figure 3. A Esophagram five months post-operatively at

the level of the tubed submental flap revealing patent

neopharynx with ample passage of contrast material.

B Lateral view of repair at eleven months post-operatively

with positive aesthetic outcome.

Figure 2. A Surgical planning of submental flap skin paddle with an extended incision planned for a right neck dissection. Reprinted from Patel et al.

B Elevation of skin paddle with a right-sided vascular pedicle, mylohyoid as part of the submental flap, ipsilateral geniohyoid (thin arrow) and

contralateral digastric muscle (thick arrow). Reprinted from Patel et al. C Gross specimen, total laryngopharynx. D Superior is to the right, inferior to

the left. Immediately prior to total laryngopharyngectomy showing extensive tumor involvement in the party wall and crossing midline. E Zippered

lateral closure with superior and inferior anastomosis. Nasogastric tube has been placed as a conduit. F Complete closure of tubed submental flap

with mylohyoid muscle on the anterior surface of the neopharynx.

A

A B C

D E F

Figure 1. Axial CT demonstrating a left hypopharyngeal

mass with obliteration of the esophagus, invasion of the

larynx, and contralateral tumor extension.

A B

Hypopharyngeal carcinomas are commonly diagnosed

at advanced stages with a poor prognosis. Surgical

ablation may render a large defect, often requiring total

laryngopharyngectomy; the reconstruction of which is

challenging. Classically, options for the reconstructive

portion include anterolateral thigh free flap, pectoralis

major myocutaneous flap, and free jejunal flap.

The tubed submental flap offers an option that has the

advantage of being both pedicled and from a single

surgical wound, thereby decreasing donor site morbidity.

Additionally, the submental flap reconstruction can be

performed in a single-stage procedure and eliminates

the need for a two-team approach.

In our experience, the tubed submental flap is reliable

and is advantageous in that it can be rapidly harvested,

has a favorable arc of rotation, eliminates the need for

microvascular surgery, and permits size variability

during design. When necessary, a large paddle

measuring up to 6 x 18 cm can be harvested depending

on the defect. In addition, the pliability of the submental

flap allows for easy tube formation.

Inclusion of the ipsilateral mylohyoid muscle with the

digastric muscle during flap harvest aids in protection of

the vascular pedicle during dissection, can reduce

operative time, and can add bulk when desired. This

may be desirable when contemplating adjuvant

radiotherapy in an attempt to decrease fistula formation.

The Submental Myocutaneous Flap for

Circumferential Neopharyngeal Reconstruction:

A Novel Technique