Mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea. An operative procedure of mediastinal tracheostomy using a pectoralis major myocutaneous flap is presented. In this procedure, the terminal portion of the trachea penetrates through the center of a pectoralis major myocutaneous flap and the tracheal wall is completely wrapped with the muscular portion of the flap. Between 1981 and 1988, eight patients with carcinoma in the cervicothoracic segment of the esophagus underwent mediastinal tracheostomy after laryngoesophagectomy and extended resection of the proximal part of the trachea through sternal manubrectomy, because of invasion into the trachea. In five of eight patients, a pectoralis major myocutaneous flap was used to construct a tracheal stoma. A skin flap only, or both a skin flap and a muscle flap, was used in the other three. In four of eight patients, tracheal necrosis occurred, and rupture of the brachiocephalic artery occurred in one patient when the tracheal stoma had been constructed using both a skin flap and a muscle flap. However, neither skin breakdown nor bleeding from the major vessels occurred when using the myocutaneous flap. Therefore, it is concluded that the construction of the tracheal stoma using a pectoralis major myocutaneous flap is recommended for mediastinal tracheostomy after laryngoesophagectomy with extended resection of the proximal part of the trachea. 