Platysma Musculocutaneous Flap for Reconstruction of Trachea in Esophageal Cancer Harutsugu Sodeyama, MD, Kiyoshi Matsuo, MD, Katsuhiko Ishizaka, MD, Chiharu Takahashi, MD, Reiko Hayashi, MD, Takai Kuroda, MD, and Futoshi Iida, MD Departments of Surgery and Plastic Surgery, Shinshu University School of Medicine, Matsumoto, Japan

In 2 patients with advanced cervical esophageal cancer invading the trachea, total laryngoesophagectomy with resection of the posterior portion of the trachea and lymph node dissection of the bilateral neck and superior mediastinum was carried out. The partial defect in the trachea was repaired with a platysma musculocutaneous

ervical esophageal cancer widely invading the tra- C chea is not usually radically operated on because of the difficulty of reconstructing the trachea. We tried a new reconstructive procedure using a platysma musculocuta- neous flap after removing the membranous wall of the trachea. We performed the procedure in 2 patients, and satisfactory results were obtained. This report describes 1 case history and details of the procedure.

Case History A 70-year-old man complained of pharyngeal pain and dysphagia for 4 months. Radiologic examination of the upper gastrointestinal tract revealed a spiral-type filling defect of the cervical esophagus, measuring approxi- mately 4.5 cm in length and extending from 1.0 cm below the pharynx to the upper margin of the manubrium sterni. Esophageal endoscopy revealed an ulcerative le- sion of the esophagus, and biopsy of the lesion showed squamous cell carcinoma. Bronchoscopy revealed multi- ple erosions with diffuse redness on the membranous portion of the trachea. The tracheal lesion extended from 4 to 8.5 cm below the vocal cords and was strongly suggestive of direct invasion by the esophageal tumor. Right recurrent nerve paralysis was noted. Computed tomographic scan also suggested direct invasion of the trachea.

Total esophagectomy with combined resection of the larynx and posterior portion of the trachea and dissection of the bilateral cervical and superior mediastinal lymph nodes was carried out. The esophagus was reconstructed with the transverse colon through the posterior mediasti- nal route, and the trachea was reconstructed as described in the next section.

Accepted for publication May 16, 1990.

Address reprint requests to Dr Sodeyama, Department of Surgery, Shin- shu University School of Medicine, Asahi 3-1-1, Matsumoto, 390 Japan.

flap. A permanent tracheostoma, composed of the tra- cheal remnant anteriorly and the platysma musculocuta- neous flap posteriorly, was made just over the manu- brium sterni.

(Ann Thoruc Surg 1990;50:485-7)

Technique A U-shaped skin incision reaching to 6 cm below the upper margin of the manubrium sterni was made (Fig 1). An extended platysma musculocutaneous flap attached to the fascia of the pectoralis major muscle was raised and a midline skin incision of about 7 cm was added for easy exposure of the upper half of the sternum. The sternum was sawed at the midline from its upper margin to the third intercostal space and cut transversely at this level making an inverted T shape. Then the superior anterior mediastinum was opened. After lymph node dissection of the bilateral paraesophageal, paratracheal, middle, and inferior internal jugular chains, the cervical esophagus was isolated with the larynx and upper part of the trachea and transected at the level of the hypopharynx. About 8 cm of the posterior portion of the trachea that was invaded by cancer was removed with the tumor, and the tracheal cartilage was preserved (Fig 2). The intrathoracic esophagus was bluntly removed through the median sternotomy without thoracotomy.

After confirming the surgical margin of the trachea to be free of cancer cells by intraoperative pathological exami- nation, we reconstructed the defect in the trachea. The extended platysma musculocutaneous flap was deepithe- lized, leaving the portion corresponding to the tracheal defect (see Fig 1). Then the flap was inserted into the superior mediastinum, and the epithelial portion was sutured to the tracheal margin, thus constructing the posterior wall. A tracheostoma was made above the ster- num (Figs 3, 4). The skin defect created by the musculocu- taneous flap was covered with a free skin graft from the right groin.

We performed this procedure in 2 patients. In both patients, the postoperative course was uneventful. Major complications such as bleeding, leakage, and infection did not occur. Respiration could be easily controlled through the intratracheal cannula.

At 1 year 4 months and 1 year of follow-up, both patients are alive without recurrence of the cancer.

0 1990 by The Society of Thoracic Surgeons 0003-4975/90/$3.50

486 HOW TO DO IT SODEYAMA ET AL OFERATION FOR CERVICAL ESOPHAGEAL CANCER

Ann Thorac Surg 1990;50:485-7

Fig 1 . A Ushaped skin incision for obtaining the pla- tysma musculocutaneous pap. Shaded area indicates deepithelized portion.

submental branch of

the transverse cervical

de-epithelized area

Comment

Many attempts have been made by surgeons to cure cervical esophageal cancer invading the trachea, focusing on the management of the involved trachea. Grillo’s [l]

tracheostomy at the anterior mediastinum is well known as a procedure to be used after wide resection of the trachea. Orringer and Sloan [2] reviewed the experience with 17 patients in whom anterior mediastinal tracheo- stomy was used, and the results are excellent, but 1

. I - Fig 3. Transposition of the platysma musculocutaneous flap to the posterior defect in the trachea. The defect created by the flap is covered with a skin graft.

Fig 2. Shading indicates area of extended resection. Arrow shows the cutting line to make a platysma musculocutaneous p a p .

Ann Thorac Surg 1990;50485-7

Fig 4. Schema of the procedure of covering the tracheal defect with the Pap.

patient died of innominate artery rupture. In 1985, Krespi and co-workers [3] improved Grillo’s procedure by using a new technique to protect great vessels with a pectoralis musculocutaneous flap. With this procedure, the risk of major complications after mediastinal tracheostomy such as suture line breakdown, infection, and bleeding could be avoided. Ong and colleagues [4] reported a procedure to close a small defect in the posterior wall of the trachea with a deltopectoral flap in a patient with locally advanced esophageal carcinoma.

Our procedure was done in 2 patients with cervical esophageal carcinoma extensively invading the posterior

HOW TO DO IT SODEYAh4A ET AL 487 OPERATION FOR CERVICAL ESOPHAGEAL CANCER

portion of the trachea. One of advantages of this proce- dure is to be able to make the tracheostoma in the cervical region by a simplified technique. We did not experience any fatal complications such as innominate artery rupture or infection. Our procedure must be safe, because the great vessels are covered by their own chest wall.

As the platysma is supplied with tlood from two vascular pedicles, the submental branch of the facial artery and the superficial branch of the transverse cervical artery [5], the submental branch of the facial artery is preserved when making the flap in our procedure.

The disadvantage of this procedure is that dyspnea sometimes develops months after operation unless an intratracheal cuffless silicone cannula is used. However, both of the present patients no longer need the intratra- cheal cannula all day long.

References 1. Grillo HC. Terminal or mural tracheostomy in the anterior

mediastinum. J Thorac Cardiovasc Surg 1966;51:422-7. 2. Orringer MB, Sloan H. Anterior mediastinal tracheostomy. J

Thorac Cardiovasc Surg 1979;78:85&9. 3. Krespi YP, Wurster CF, Sisson GA. Immediate reconstruction

after total laryngopharyngoesophagectomy and mediastinal dissection. Larygoscope 1985;95:156-61.

4. Ong GB, Lam KH, Lim STK, Wong J. Salvage operations for malignant obstruction of the esophagus. Aust NZ J Surg 1979;49:573-6.

5. Coleman JJ, Jurkiewicz MJ, Nahai F, Mathes SJ. The platysma musculocutaneous flap: experience with 24 cases. Plast Recon- str Surg 1983;72:31523.