Surgical Technique
Reconstruction is performed following laryngectomy and circumferential pharyngectomy +/- cervical oesophagectomy. A DP flap is raised in the subfascial plane. The blood supply from the 2nd and 3rd internal mammary perforator arteries allows harvesting of a broad tissue flap with a width extending from the clavicle to the 5th intercostal space, and a length reliably extending towards the shoulder tip. The flap is sutured onto the posterior oropharyngeal mucosa superiorly, and the proximal oesophagus inferiorly (Figure 1). In one individual, the superior extent of the flap repair extended to the level of the soft palate. Total time required to raise the DP flap and suture it to the inferior edge of the oropharynx is approximately 30 minutes.
A second flap is then harvested. This can be a free flap or a pedicled flap. In our series, a pectoralis major myocutaneous flap or a supraclavicular fasciocutaneous flap on the opposite side was used. This is to form the anterior and lateral pharyngeal wall. This second flap is raised and inserted in a similar manner to a partial pharyngeal patch repair. 3,7
The distal part of the deltopectoral cutaneous tissue is left to form the posterior pharyngeal wall and skin de-epithelialisation is performed to a small middle segment of the flap, so that the only cutaneous tissue buried within the neck is the neopharynx itself (Figure 2). The skin of the deltopectoral flap near the stump of the oesophagus is sutured, thereby ensuring the integrity of the neo-posterior pharyngeal wall from oropharynx to oesophagus.
The second flap can then be sutured to the anterior mucosa of the proximal oesophagus, the DP flap laterally, and the tongue base superiorly, creating a conical neopharynx. Flap harvest sites are then closed primarily. A salivary bypass tube is positioned in the reconstructed neopharynx to help the healing process splinting it open, which is subsequently removed 3 weeks later, prior to commencement of oral diet. Six-month post-operative outcome is displayed in Figure 3.