New Concept of Flap Configuration for Head and Neck Reconstruction (2012)

Sir:FigureAdvances in sensory reconstruction and microvascular neuroanastomosis have not led to effective gains in lost function resulting from tumor resection.1 That is, residual live tissue should be used to maximize postoperative eating or speech function instead of harvesting flaps. Aged patients with resection that includes, for example, the tongue, oral cavity, and pharynx are at very high risk for gastric tube dependence. In this communication, we describe reconstruction after tumor resection from the maxilla/tongue/middle pharynx to the hypopharynx in an aged patient that resulted in good postoperative function. A 76-year-old woman underwent resection to treat left maxillary, tongue, oropharynx, and hypopharynx carcinoma (T4N2bM0) (Fig. 1). The patient could ingest food orally using dentures preoperatively, but postoperative aphagia was predicted because multidomain resection was planned. The insertion of a flap for the oral region and pharynx was minimized because we considered that it would result in postoperative aspiration and the flap would expose broadly. We initially formed a tongue tip of approximately 2 cm. Next, the residual mucosa was sutured from the cervical part of the pharyngeal defect so that the degree of lingual motion would not be limited. The tip of a ginkgo-type, free rectus abdominis myocutaneous flap was posted to the pharyngeal inferior extremity, maxilla, and tip of the tongue (Fig. 2). We considered the flap configuration to easily maintain deglutition pressure using the residual glossa. Therefore, the defect caused by tumor resection was covered with a flap with a sufficiently abundant volume to preserve the small oropharyngeal isthmus. The volume of the intraoral flap remained good after postoperative swelling subsided with atrophy at 2 months after surgery. The patient can orally ingest food without limitation and with good tongue motion.Fig. 1: Preoperative oral cavity (left) and resection range (right).Fig. 2: Harvested ginkgo-type flap (left) and flap configuration (right).Several reports have described a device with which to insert a large flap with the same configuration as a defect to reproduce the original form. In contrast, little is known about the association between postoperative function and optimal flap shape for head and neck reconstruction.2–4 Our experience of head and neck reconstruction has led to consideration of the following critical factors including the tongue, oral cavity, and middle pharynx: The surviving mucosa should be sutured as much as possible within the limits to not affect lingual motion. Exposure of flap tissue without normal sensation to the oral or pharynx cavity should be minimized. An abundant flap volume should be transferred to the oropharyngeal isthmus to reconstruct the narrow pharynx and maintain deglutition pressure. An appropriate volume of adipose tissue that is resistant to becoming atrophic postoperatively should be placed in the necessary locus of the defect. Muscle volume decreases approximately 30 percent with denervation in the long term after surgery.5 Some patients develop long-term difficulties with ingestion when a defect is mainly replaced with muscle that becomes atrophic. We filled the oropharyngeal isthmus with adipose tissue to prevent postoperative atrophy. We believe that reproducing the original configuration is not as important as maximizing remaining natural function. Satoshi Onoda, M.D. Yoshihiro Kimata, M.D., Ph.D. Hiroshi Matsumoto, M.D. Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Dentistry, and Pharmaceutical Science, University of Okayama, Okayama, Japan DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.