British Journal of Plastic Surgery (1982) 35,401-407 0 1982 The Trustees of British Association of Plastic Surgeons

0007-1226/82/0400-0401 $02.00

Pharyngeal reconstruction using the latissimus dorsi myocutaneous flap J. S. WATSON, G. A. ROBERTSON, J. LENDRUM, M. F. STRANC and M. J. POHL

Plastic and Reconstructive Surgery Centre, St. Lawrence Hospital, Chepstow; Section of Plastic Surgery, University of Manitoba, Winnipeg and the Plastic Surgery and Burns Unit, University Hospital of South Manchester, Withington Hospital, Manchester

Summary-A technique of reconstruction of the pharynx and cervical oesophagus using a latissimus dorsi island flaD is Dresented. The indications and complications of this particular method of reconstruction are discussed.

Many methods exist for reconstruction of the pharynx and the cervical oesophagus. Well- established techniques include the Wookey procedure, tubed delto-pectoral skin flaps and gastric or intestinal pull-throughs. More recently, two major new techniques have been described. The first method involves free gastric or jejunal transfer with microvascular revascularisation, used with success by Baudet ef al. (1978) and May and Bunting (1977). The second method involves the use of a myocutaneous flap employ- ing variously the pectoralis major (Theogaraj et al., 1980; Biller et al., 1981; Withers et al., 1981), the latissimus dorsi (Watson and Lendrum, 1981; Ali et al., 1982), the sternomastoid (Ariyan, 1979) and the trapezius (Bertoti, 1980). This article presents the uses and advantages of the tubed latissimus dorsi island flap.

lateral position, so that the donor site for the flap can be prepared and the drapes sutured in place. The patient can then be rolled supine and the head and neck preparation completed. When the neck is ready to receive the flap, the patient is rolled on to the side in order that the flap can be raised without the need for any further skin preparation to interrupt the surgery. When the flap is raised and the tunnel dissection com- pleted, the distal two-thirds of the back wound is closed and the patient rolled supine again, to complete the reconstruction and the back closure.

Mobilising the muscle

Method

A latissimus dorsi myocutaneous flap is raised as a true island on the artery and vein only. The nerve to the flap should be cut in order to reduce muscle bulk. The flap comprises virtually the whole of the muscle together with a skin paddle up to 10 cm in width and 15 cm in length.

The development, anatomy and surgical approach to the latissimus dorsi flap are well documented for a wide variety of clinical situa- tions (Bailey, 1979; Bartlett et al., 1981; Maxwell et al., 1978; McGraw et al., 1978; Quillen et al., 1978; Tobin et al., 1981; Watson et al., 1979).

In this paper the various points of technique will be described only as they relate specifically to the problem of pharyngeal reconstruction.

The pedicle is developed to the origin of the circumflex scapular artery and the flap delivered to the neck through a wide tunnel under the pectoralis major muscle, but superficial to the pectoralis minor muscle and the clavicle. Should the tunnel appear too snug, a split can be made in the clavicular portion of the pectoralis major.

Planning the skin pad&e

Positioning the patient

When using the latissimus dorsi flap, it is neces- sary to turn the patient twice during surgery. This inconvenience is minimised if the patient is initially placed on the operating table in the JPS-B ,,,

The positioning of the skin paddle on the muscle is critical. It should be placed as distally as possible on the muscle, in order to give the flap its maximum reach to allow maximum flexibility when insetting the skin tube and its muscle seal. McGraw stated in 1975 that the flap could be taken to within 5cm of the posterior iliac crest

4uI

402 BRITISH JOURNAL OF PLASTIC SURGERY

without requiring a delay. This remains a sound guide-line but in the elderly or debilitated patient it may need to be positioned more proximally. It is our practice to raise the whole muscle and to take the skin paddle paddle to within 8cm of the posterior iliac crest. When the muscle has been delivered to the neck, the distal portion can be trimmed if there is doubt of its viability. The axis of the skin paddle on the muscle is important and must be determined by reverse planning. The axis of the skin paddle should be oblique to the long axis of the latissimus dorsi muscle; it will then lie in the correct position when the muscle is angled in to the neck.

Securing the reconstruction

The skin is either tubed or attached to the remaining pharyngeal mucosa with inverting sutures, The oesphagus is divided obliquely to increase the diameter of the lower anastomosis.

The reconstruction is sealed by a muscle layer closure at the upper anastomosis to the base of the tongue around the oesophageal anastomosis by carefully placing muscle between the oeso- phagus and the tracheostome. In addition, the muscle is either tubed completely around the skin tube (Fig. 2) or sutured to the pre-vertebral fascia on either side. The latter is performed either when a posterior pharyngeal mucosal strip remains or when the rest of the neck requires the imported blood supply of the latissimus dorsi muscle. It is important that the width of the muscle be greater than the width of the skin paddle, as otherwise shearing or compression of the vascular links between the two can occur on attempts at tubing. This point can be clearly demonstrated using a foam model (Fig. 1).

Cover of the reconstruction can be achieved with intact neck skin, a second flap, a double- paddled latissimus dorsi flap (Fig. 3) or a skin graft to the muscle pedicle (Fig. 4), depending on individual need. A naso-gastric tube is placed through the reconstruction for feeding the pa- tient. Fluids are usually started live days post- operatively and feeding commenced later.

Clinical experience

The latissimus dorsi flap has been used in 16 pharyngo-oesophageal reconstructions. In three patients a posterior mucosal strip was incorpo- rated; six were total reconstructions under intact neck skin. Five were total reconstructions where

no neck skin cover was present: cover was provided by grafts on the muscle in three cases (Fig. 2) a double latissimus dorsi skin paddle in one case (Fig. 3) and a delto-pectoral flap in one case. In two cases the flap was sutured to the base of the tongue and the lower end of the skin tube left to the side of the neck to direct the saliva away from the tracheostomy and the muscle was used to cover the exposed carotid vessels. The oesophageal opening was judged to be impossibly low to complete the anastomosis and in addition tumour recurrence was suspected and proved by biopsy. These two latter patients were late reconstructions. Six patients were reconstructed at the time of pharyngolaryn- gectomy, while ten were late reconstructions. Their ages ranged from 38 to 73 years. Follow- up has been from 3 to 24 months. Three patients had a supra-glottic squamous cell carcinoma, seven patients had a trans-glottic squamous cell carcinoma and six had a hypo-pharyngeal or cervical oesophageal carcinoma. Thirteen patients had radiotherapy prior to any surgery.

Complications

The following complications were encountered in this series. In one patient the latissimus dorsi flap failed completely, due to compression of the pedicle between the clavicle and the pectoralis major muscle. This was regarded as a technical error, which is avoidable. It was due to an inadequate tunnel because the clavicular origin of the pectoralis major was not detached sufficiently from the clavicle. Subsequently, a second latis- simus dorsi flap was used together with two delto-pectoral flaps to reconstruct and resurface the neck.

Two early cases developed large lateral listulae (contralateral to the side from which the flap was raised) requiring a second flap. One was due to planning the skin paddle too proximally on the muscle and’ failing to get an adequate muscle seal around the reconstruction. The other was a late reconstruction with total loss of neck skin and exposure of the carotid vessels. In this case the latissimus dorsi muscle, at its distal end became necrotic post-operatively, re-exposing the recon- struction. The patient was very debilitated and developed a post-operative pulmonary collapse, which probably contributed to further necrosis of

PHARYNGEAL RECONSTRUCTION USING THE LATISSIMUS DORSI MYOCUTANEOUS FLAP 403

Fig. 1A. Foam model of an inverted myocutaneous tube. The skin. fat and muscle incised in same vertical plane.

the muscle. The reconstruction was completed in both cases with a pectoralis major muscle flap to plug the fistulae.

One complete reconstruction developed a very small but persistent lateral fistula, which was closed successfully in two layers at a second operation.

One complete reconstruction developed a mild degree of stricture at the lower anastomosis, which was revised successfully at a second operation. This was the only stenosis in 14 reconstructions to date.

Discussion

Comparison of myocutaneous jlap reconstruction and free intestinal transfers

In a suitable case, such as a younger patient with intact neck skin and without serious radiotherapy damage to the neck, the free intestinal transfer provides the most sophisticated reconstruction. It does, however, require intra-abdominal surgery with its possible sequelae and it requires a

Fig. 1B. Shearing of the layers on attempting to invert the successful- microsurgical revascularisation. One

tube. Should a complete tube be formed, then compression criticism of a skin tube reconstruction in the past on the inner layer will result in necrosis. has been the possibility of stenosis at the lower

404 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 1C. The muscle layer is cut deliberately wider than the other layers.

Fig. 1D. All the layers tit without tension when the tissues are tubed.

anastomosis, which does not happen after an intestinal transfer. In our series of 11 complete skin tube reconstructions, we have only met the problem of stenosis in one patient as mentioned above. When a posterior pharyngeal mucosal strip is incorporated in the reconstruction steno- sis will not occur.

Advantages of myocutaneous flap reconstruction over delto-pectoral flap reconstruction

The blood supply of the myocutaneous flap is in general far superior to that of the delto-pectoral flap, especially in the elderly and debilitated patient. The muscle of the compound flap allows the pharyngeal reconstruction to be sealed off with a second layer closure. This is a major advantage, reducing considerably the incidence of salivary leakage. If no neck skin is available, a split-skin graft on the muscle provides a simple method of skin cover. Furthermore, should intact neck skin be used which subsequently breaks down, it is only the muscle of the reconstruction which is exposed and this can be simply skin- grafted without hazard to the reconstruction. The muscle of the flap can also be used to cover the carotid arteries, if exposed, and to obliterate any dead space in the neck.

TRUCTION USING THE LATISSIMUS DORSI MYOCUTANEOUS FLAP 405

Comparison of latissimus dorsi reconstruction with other myocutaneous flap reconstructions, particularly the pectoralis major jlap

The latissimus dorsi is a very large muscle and this bulk of tissue may be needed in a badly damaged neck. Full development of the pedicle, as described, allows for great manoeuvrability in the neck. The muscle can carry a large area of skin, enabling the use of a double paddle if necessary. All these three features can be claimed for the pectoralis major flap as well as the latissimus dorsi flap. However, there are times in the female patient when the breasts may interfere with the planning of the skin paddle and add bulk to the thickness of the flap. In a male patient the presence of hairy skin may favour the choice of the latissimus dorsi flap.

In a young female patient the latissimus dorsi

donor site defect may be preferred to the pector- alis major defect. If the skin paddle is no more than 10-11 cm in width, it can be closed prima- rily producing a linear, albeit stretched, scar. If the patient has not had a block dissection of the neck with division of the accessory nerve, full shoulder movement will return after a latissimus dorsi flap. If there has been division of the accessory nerve there may be difficulty in raising the arm above a right angle. However, we have observed that the combination of accessory nerve division and a pectoralis major flap may also produce the same difficulties. It is our practice to take the latissimus dorsi flap from the side of the non-dominant arm.

Bearing in mind the possibility of the com- plications listed above, the procedure is in most instances a one-stage reconstruction even in the most severely damaged neck. It is recommended that the reconstruction is performed at the time of the pharyngolaryngectomy.

406 BRITISH JOURNAL OF PLASTIC SURGERY

C D

Fig. 3 The use of a tube skin paddle. A. The muscle is raised with two separate skin islands. B. The proximal island is being set into the anterior defect. C. The distal island is folded back and used as cover. D. Appearance six weeks after operation.

Watson, J. S. and Lendrum, J. (1981). One-stage pharyngeal reconstruction using a compound latissimus dorsi island flap. British Journal of Plastic Surgery, 34, 87.

Fig. 4 The reconstruction shown in Figure 2 at six weeks. Withers, E. H., Franklin, J. D, Madden, J. J. and Lynch, J. B.

Cover has been provided by a split-skin graft over the muscle. (1981). Immediate reconstruction of the pharynx and cervical oesophagus with the pectoralis major myocutaneous flap following laryngopharyngectomy. PIustic and Reconstruc-

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