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frequently cited being the deltopectoral (DP) flap, the internal mammary artery
perforator (IMAP) flap, the pectoralis major myofascial (PMMF) and myocutaneous (PMMC) flaps, and the supraclavicular artery island flap (SCAIF)
(Table8.2).
Table 8.2 Locoregional aps. Blood supply, advantages, and disadvantages
Reconstructive
Flap Blood supply
Deltopectoral Internal mammary
artery and vein,
deltoid perforators
from thoracoacromial
trunk and anterior
circumex vascular
bundle
Internal
mammary artery
perforator
Pectoralis major
Myocutaneous
Pectoralis major
myofascial
Supraclavicular
Artery Island
Internal mammary
artery and vein
Thoracoacromial
artery and vein
Thoracoacromial
artery and vein
Supraclavicular artery
and vein
capability Advantages Disadvantages
Tubed
(circumferential
defects)
Onlay/patch
Tubed
(circumferential
defects)
U-shaped
(circumferential
defects)
Onlay/patch
Onlay/patch
Onlay/patch Thin and pliable
Safe
management of
airway and
salivary
formation
Thin and pliable,
minimal
tracheostomal
obstruction
Decreased donor
site morbidity
when compared
to deltopectoral
(DP) ap
Ease of harvest,
single surgeon
team
Can be used in
vessel depleted
neck
Minimal donor
site morbidity
Can be used to
reconstruct
anterior neck
skin
Presence of
stula
Donor site
morbidity, need
for split
thickness skin
graft (STSG)
Distal tip
necrosis
Two-stage
surgery
Small-medium
sized defects
only
May require
resection of rib
cartilage
Can alter breast
contour
Flap bulk results
in worse speech/
swallowing
outcomes
Shoulder and
arm weakness
Chest wall
contour
asymmetries
Can alter breast
contour
Small-medium
sized defects
only
Extensive neck
dissections may
have transverse
cervical arteries
ligated
Anatomic
variations in
vascular pedicle
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Locoregional reconstruction of the pharynx was rst reported in 1886, but was
not popularized until Wookey introduced the pedicled cervical ap in the 1940s
[31]. The Wookey ap was a two-staged reconstruction using a platysmal cervical
skin ap tacked to prevertebral fascia. This eventually formed the neopharynx to
be closed in a second stage. Salivary contamination, subsequent mediastinitis and
great vessel rupture was a frequent occurrence with the Wookey ap, and thus, it
has largely been abandoned for the more common locoregional aps used
today [32].
R. Y. Wang et al.
Deltopectoral andInternal Mammary Artery Perforator Flap
The deltopectoral (DP) ap was rst reported as a reconstructive option for pharyngeal reconstruction by Bakamjian in 1965 [33]. It was the primary reconstructive
method for head and neck defects up until the 1980s, when the pectoralis major
aps and microvascular free tissue transfer became popularized. While it is less
frequently used for pharyngeal reconstruction today, it paved the way for current
techniques in pharyngeal reconstruction.
The DP ap was initially described as a two-stage perforator ap based on three
separate blood supplies: (1) the rst to fourth perforators of the internal mammary
artery and veins, which are located parasternally; (2) the deltoid perforators arising
from the thoracoacromial trunk; and (3) the anterior circumex vascular bundle that
accompanies the deltoid muscle laterally. Given the less reliable nature of the lateral
vasculature, the ap is typically harvested based medially on the internal mammary
blood supply. A horizontal incision is made below the clavicle and brought inferiorly to the fourth intercostal space. The ap is then elevated deep to the supercial
pectoral and deltoid muscle fascia [34]. The ap is tunneled into the defect site,
tubed longitudinally, and sutured to the oropharynx superiorly. The esophagus is
sutured to the base of the DP ap, thus creating a controlled salivary stula site. The
donor site is closed with a split thickness skin graft (STSG). A second stage for division and inset of the ap and closure of the salivary stula is performed 4weeks
later. This approach had signicant advantages over the Wookey procedure including safe management of the airway and salivary formation. However, the need for
multiple-staged surgeries, persistent salivary stula prior to second stage, donor site
morbidity with inability to obtain primary closure, and unreliability of the distal tip
of the ap are major drawbacks [32]. Today, the DP ap is utilized less frequently
due to the improved versatility and lesser donor site morbidity afforded by the
supraclavicular and pectoralis major aps for similar defects.
The DP ap has most recently been redened by Yu etal. in 2006 as the internal
mammary artery perforator (IMAP) ap and is most commonly described today as
such [35]. Basing the pedicle off one arterial supply rather than three as in the DP
ap allows for a greater arc of rotation [36]. The internal mammary artery perforator
of interest can be found using a Doppler and traced out from the parasternal region.
The stronger signal of the second or third IMAP is typically chosen for the vascular
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bundle. Dissection is similarly carried deep to the muscular fascia, and the ap is
tunneled into the defect site in a subcutaneous fashion. Some have reported resecting the associated rib cartilage to allow for better exposure of the vascular bundle.
In general, the IMAP ap is thinner, resulting in decreased donor site morbidity
compared to the DP ap.
DP and IMAP aps can be used as onlay aps or as a tubed ap in cases of circumferential pharyngeal defects [37]. The IMAP ap has also frequently been
reported for its use in repair of pharyngocutaneous stulas and is, therefore, an ideal
backup option in case of primary ap failure or complication. Advantages of the
IMAP ap include its thin and pliable design, allowing for adequate reconstruction
without risk of tracheostomal obstruction [38]. However, the inability to close the
donor site primarily in most cases and poor cosmesis that results are signicant
drawbacks that limit utilization of the IMAP ap.
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Pectoralis Major Myofascial andMyocutaneous Flap
The pectoralis major (PM) ap is perhaps the most reported regional ap used in
pharyngeal reconstruction and is a workhorse in head and neck reconstruction. It
was rst described by Ariyan in 1979, where its use was described for various head
and neck defects ranging from orbital exenteration to oral cavity and oropharyngeal
resections [39].
The pectoralis major ap is based on the thoracoacromial artery, which branches
from the axillary artery and then travels under the clavicle for approximately 2–4cm
before coursing obliquely in an inferomedial direction along the pectoralis major
muscle. The PM ap is classically harvested through a parasternal incision carried
down to the pectoralis fascia. The muscle is then elevated off the chest wall from an
inferior to superior direction. The neurovascular bundle can be found on the deep
surface of the muscle in the fatty plane separating the pectoralis major and minor
muscles. Dissection can then be carried as far wide and proximal as necessary to
cover the defect extent. Once defect dimensions are known, the pedicled ap can be
released from its attachments, including the humerus. Keeping the vascular pedicle
intact, the ap is mobilized and transferred through a subcutaneous tunnel into the
neck [34].
The PM ap can be harvested and inset as either a myofascial ap (PMMF) or a
myocutaneous ap (PMMC). For pharyngeal reconstruction, the PMMF ap is typically used in an onlay fashion and leaves behind the skin and subcutaneous tissue
overlying the pectoralis major. In onlay reconstruction, the pharynx is rst closed
primarily in a tension-reducing T- or Y-pattern [40]. The PMMF is then sutured to
the base of tongue, pharyngeal constrictor muscles, and posterior wall of the trachea
to lay external to the primary pharyngeal closure and serve as a vascularized wound
bed to assist in pharyngeal healing. Retrospective series have shown mixed results
with regards to PCF formation in PMMF ap onlay compared to primary closure
alone. Some have shown a decreased PCF formation, whereas others have shown a
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R. Y. Wang et al.
similar rate of PCF formation but decreased size and severity of stula formation
[7, 40–43].
The PMMC ap was initially described by Fabian in 1984 and later simplied by
Spriano etal. in 2001 [44, 45]. It is most commonly used as an anterior patch graft
when a posterior mucosal pharyngeal strip is left. If a circumferential pharyngeal
defect exists, the PMMC ap can be partially tubed and either sutured directly to prevertebral fascia or with an STSG overlying the prevertebral fascia. In these situations,
the PMMC ap serves as the anterior and lateral walls of the neopharynx, and the
prevertebral fascia/STSG serves as the posterior wall. The PMMC ap in theory can
be completely tubed and was historically done prior to the advent of free aps; however, given their high incidence in pharyngeal stricture, it is infrequently performed [46].
The PM ap has several major advantages, including relative ease to harvest,
decreased time in the operating room, and only requiring a single surgeon team.
These are particularly advantageous in the patient with multiple comorbidities that
may not be able to withstand longer periods of time under general anesthesia.
Additionally, in patients with an irradiated neck, microvascular reconstruction may
be challenging due to the vessel depletion.
Multiple studies have evaluated rates of pharyngocutaneous stula after salvage
laryngectomy with primary closure, pedicled ap reconstruction (primarily with
pectoralis major aps), or MVFTT (predominantly RFFF and anterolateral thigh
free ap (ALT)) [7, 40, 42, 47–52]. Most studies have demonstrated elevated risk of
PCF with primary closure, with rates ranging from 9% to 57%, though with conicting ndings regarding the comparison between pedicled ap and MVFTT
reconstruction [7, 42, 49, 52]. In a promising early series published in 2009, Patel
etal. found that overlay with PMMF after laryngectomy reduced the rate of PCF to
0% in both the primary and salvage setting [42]. A subsequent meta-analysis demonstrated a 22% decreased risk of stula with PMMF compared to primary closure
alone [53]. While data regarding radiation history and other complications was not
reported, this study nonetheless suggested a role for routine prophylactic PMMF in
the salve setting to reduce the rate of PCF.
While PM aps have many advantages, its major disadvantage is the bulk that
comes from the pectoralis major muscle. Even with denervation and subsequent
muscle atrophy, tissue bulk can often tether the tongue and limit its mobility. This
can lead to poor functional outcomes, including difculty with articulation, speech,
and swallowing. This tissue bulk can often impede tracheoesophageal speech
through impairment of the vibratory quality of the neopharynx [17]. In comparison
to patients undergoing primary closure, Deschler etal. showed patients with PM
ap reconstruction had a functional voice with similar intensity, pitch, and range;
however, the PM ap group was found to have poorer intelligibility, communicative
effectiveness, pitch and loudness usage, and uency compared to those who underwent primary closure [54]. In addition to these functional disadvantages, the PM
aps are associated with donor site morbidity, including shoulder and arm weakness
and chest wall contour asymmetries [17]. Given these disadvantages, the PM aps
are traditionally reserved as a backup reconstructive option in the event that initial
reconstructive attempts fail.
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Supraclavicular Artery Island Flap
The supraclavicular artery island ap (SCAIF) has gained popularity for pharyngeal locoregional reconstruction in recent years. The ap is based on the supraclavicular artery and vein, which branches off the transverse cervical vessels
approximately 3–4cm from their origin off the subclavian vessels. The supraclavicular vascular bundle can be found in a triangle composed of the posterior edge
of the sternocleidomastoid muscle (SCM), the external jugular vein, and the
medial aspect of the clavicle The incision is started lateral through the distal part
of the ap superior to the deltoid muscle. Dissection is performed in a subfascial
plane elevating from lateral to medial. The pedicle can sometimes be identied in
the medial third of the ap, but may not always be able to be visualized. Once the
medial limit of dissection is met, the overlying skin is supercially incised down
to subcutaneous tissue on the superior side of the ap and subfascial on the inferior side of the ap to create a tunnel. The ap is then pulled through the tunnel
to reconstruct the pharyngeal defect [55]. If one side of the neck is at risk for
great vessel exposure due to prior surgery or radiotherapy, it is recommended to
harvest the SCAIF from the affected side, as the proximal soft tissue pedicle can
provide vessel coverage in addition to pharyngeal closure. Otherwise, it is recommended to use the patient’s nondominant side to minimize donor site morbidity [56].
Emerick etal. reported a large case series in 2014 demonstrating the utility of
this ap and popularized its use in pharyngeal reconstruction [56]. The SCAIF can
be used as an adipofascial ap to reinforce primary pharyngeal closure in an onlay
fashion or as a fasciocutaneous ap to serve as a patch graft in a partial pharyngeal
defect. Reconstruction with a tubed SCAIF for circumferential pharyngeal defects
has been reported, though this is infrequently performed due to limitation in ap
width that can be harvested [57–59].
A major benet of the SCAIF is its ability to reconstruct anterior neck skin
(Fig. 8.3). This is particularly useful in cases of salvage laryngectomy where
reduced skin elasticity after radiation can make primary closure challenging. It is
also helpful in tracheostomy-dependent patients, where excision of stromal tissue
leaves a cutaneous defect. The SCAIF tissue is an excellent thickness match for this
area of the neck, especially in comparison to PM aps. The SCAIF has very minimal donor site morbidity. Similar to other locoregional reconstructive options, the
SCAIF can be quickly harvested and can be performed by a single surgeon
team [56].
The SCAIF can only be used in selected patient populations. Those undergoing
extensive neck dissections may have their transverse cervical vasculature ligated,
which removes the SCAIF as a reconstructive option. Additionally, some have experienced variable success due to anatomical variations in the vascular pedicle. This
can be potentially be avoided through the use of Doppler to trace out the vessels
prior to ap harvest [56].
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Fig. 8.3 Supraclavicular artery island ap (SCAIF) reconstruction of the anterior neck following
laryngectomy
R. Y. Wang et al.
Microvascular Free Tissue Transfer (MVFTT)
Visceral aps such as jejunal aps were originally described in pedicled fashion for
esophageal reconstruction and have been utilized as free aps in animal models
since as early as 1959 [60]. Over the past several decades, MVFTT has emerged as
a popular modality for reconstruction of complex defects throughout the head and
neck [61]. With recent advances in surgical technique and postoperative care, head
and neck MVFTT has become increasingly reliable with failure rates ranging from
0 to 3.8% in recent series [62, 63]. A variety of donor sites have been described in
the literature for pharyngoesophageal reconstruction since the 1980s (Table8.3) and
offer a range of options to t each patient’s defect. Fasciocutaneous thigh-based and
forearm-based free aps were the rst described for pharyngoesophageal reconstruction and remain among the most popular options to this day. Careful consideration of patient factors (comorbidities, body habitus, prior surgery, prior radiation
history, etc.), the anticipated defect, and donor site morbidity are mandatory for
successful MVFTT reconstruction.
Forearm Free Flaps
Originally described by Yang etal. in 1981, the radial forearm free ap (RFFF) has
emerged as a workhorse ap in head and neck reconstruction [64, 65]. Relative ease
of harvest, long pedicle length, and thin, pliable tissue make it a versatile option for
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Table 8.3 Free aps utilized
in laryngopharyngeal
reconstruction
Upper extremity
Radial forearm free ap (RFFF)
Ulnar forearm free ap (UFFF)
Lateral arm free ap
Lower extremity
Anterolateral thigh free ap (ALT)
Anteromedial thigh free ap (AMT)
Profunda artery perforator ap (PAP)
Medial sural artery perforator ap (MSAP)
Tensor fascia Lata free ap (TFL)
Subscapular system
Parascapular free ap
Latissimus Dorsi free ap
Head and neck
Temporoparietal fascia free ap
Abdominal
Jejunal free ap
Gastro-omental free ap
Fig. 8.4 “Shield” design of radial forearm free ap
a variety of defects. The radial forearm free ap is based on the radial artery as it
courses toward the wrist with deep venous drainage coming from venae comitantes
associated with the radial artery, but can also be designed to include supercial
accessory drainage from the cephalic vein. The skin paddle is typically centered
over the radial artery and may be designed in a shield pattern to account for the
greater circumference at the base of tongue compared to the esophagus (Fig.8.4). A
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preoperative Allen’s test, either by clinical examination or by duplex sonography,
should be performed to ensure adequate perfusion to the hand through an intact
palmar arch will be maintained after sacrice of the radial artery. The ap is typically harvested from the nondominant hand to minimize functional decits after
surgery. In most cases, the donor site defect cannot be closed primarily and requires
either skin grafting or local ap closure. Typically the wrist is kept in a splint for
several weeks to prevent shearing of the skin graft from the underlying tendons and
musculature. Donor site morbidity is typically minor, but can include decreased grip
strength and range of motion, hypesthesia from injury to the supercial branch of
the radial nerve, and poor cosmesis [66]. Flexor carpi radialis tendon exposure can
develop due to failure of the overlying skin graft from shearing and if left untreated
can result in impaired mobility of the wrist [67]. The exposed tendon may be covered with a skin graft, local ap, or biologic dressing to facilitate healing [66].
Described as an alternative to the radial forearm free ap in the 1980s, the ulnar
artery perforator free ap (UAPFF) serves as another option for reconstructions
requiring thin, pliable tissue [68]. The UAPFF is a thin ap with the additional benet of allowing chimeric design with multiple independent skin paddles based on
individual perforators. The perforators can be identied using preoperative Doppler
assessment when planning for chimeric designs. The skin of the medial forearm
also tends to be less hirsute than that of the lateral forearm, which can be an advantage in oral cavity reconstruction (particularly after glossectomy), though this is less
critical in pharyngeal reconstruction. However, given concerns that sacricing the
ulnar artery would compromise blood ow to the hand and the risk of injury to the
ulnar nerve during pedicle dissection, the ulnar forearm free ap has been less popular than the radial forearm [69]. Furthermore, the pedicle tends to be slightly shorter
than that of the radial forearm with smaller-caliber vessels, particularly in the ulnar
vena comitantes [69]. In patients in whom a radial forearm ap is not an option or a
more complex chimeric design is desired for multilayered or through-and-through
defects (e.g., for reconstruction of tracheoesophageal stulae), the UAPFF serves as
a useful alternative to the RFFF [70].
Since Harii etal. rst utilized the RFFF in pharyngoesophageal reconstruction as
a tubed ap in 1985, a variety of modications have been described to address additional reconstructive concerns [61, 71]. For example, subcutaneous fat and fascia
may be harvested around the vascular pedicle to provide additional bulk and protection at the anastomosis, or an additional skin paddle can be designed to serve as an
external monitor paddle [72, 73]. The medial or lateral antebrachial cutaneous nerve
can also be harvested with the UAPFF or RFFF to create a sensate ap [74]. Because
of the pliability of the tissue, the forearm aps can be folded to reconstruct the pharyngeal defect and skin simultaneously [75]. This technique can also be applied to
reconstruct the tracheal and esophageal walls in patients who develop tracheoesophageal stulae (TEF) after tracheoesophageal puncture [76]. The RFFF is much less
bulky than the pedicled pectoralis ap or most other free aps, making it a good
option in overweight and obese patients. This decreased bulk also facilitates recovery of swallowing function postoperatively and restoration of speech with tracheoesophageal puncture [77–79]. However, this may come at the cost of increased risk
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of postoperative pharyngocutaneous stulae relative to other reconstructive options
[79]. Early studies with RFFF demonstrated rates of PCF ranging from 17% to 25%
with higher rates of stula and anastomotic stricture with tubed RFFF, particularly
when compared to jejunal free aps [79–81]. While direct comparisons with patients
undergoing primary closure or pedicled aps were not available in these studies,
these rates of complications are comparable to those described with the PMMF.
Anterolateral Thigh Free Flap (ALT)
Along with the RFFF, the ALT free ap has been established as one of the primary
options for soft tissue reconstruction of the head and neck. First described as a fasciocutaneous ap based on perforators from the descending branch of the circumex femoral artery by Song et al. in 1984, the ALT can also be harvested as a
myocutaneous, adipofascial, or even osteocutaneous ap by including muscular
perforators to the vastus lateralis muscle or femur cortex [82]. With the possibility
of multiple skin paddles based on individual perforators and including vastus lateralis muscle supplied by perforators from the distal pedicle, the ALT has great versatility to t a variety of complex defects (Fig.8.5). The pedicle tends to be quite long
with large vessel caliber [82]. If desired, it can also be harvested with the lateral
femoral cutaneous nerve to create a sensate ap. Donor site morbidity tends to be
minimal, although the long incision along the lateral thigh can be unsightly. Primary
closure of the donor site can often be achieved after harvest of wide fasciocutaneous
components (up to approximately 10cm depending on skin laxity). The bulk of the
ap can be a limitation in some cases, as the ap can be quite thick in obese patients.
The perforator anatomy of the ALT free ap can also be somewhat variable; in some
cases, perforators from the lateral circumex femoral artery may be absent, necessitating conversion to the anteromedial thigh (AMT) ap based on a medial
Fig. 8.5 Anterolateral
thigh free ap with
pedicled vastus lateralis
muscle ap. (a) Pedicle,
(b) Skin perforators, (c)
Skin paddle, (d) Vastus
lateralis, (e) Rectus
femoris, (f) Vastus
intermedius
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Fig. 8.6 Chimeric anterolateral thigh free ap (ALT) microvascular free tissue transfer (MVFTT)
reconstruction of a total laryngopharyngectomy requiring anterior neck soft tissue reconstruction
descending branch [83]. Evaluation of perforator anatomy using the Doppler can be
helpful for planning purposes, particularly when very large skin paddles or chimeric
designs are desired. Because much of the ap can be raised without committing to
specic dimensions on the skin paddle, ap harvest can start earlier in the case
before the nal defect size is known, allowing for greater efciency.
As with the RFFF, the ALT can be used both as an interpositional or patch design
and as a tubed graft after total pharyngectomy. In cases where skin resection is
required or there is insufcient skin laxity for closure, as is often the case in salvage
cases after prior radiation, an additional skin paddle can be harvested in a chimeric
fashion to resurface the skin and serve as a monitor paddle (Fig. 8.6) [51].
Alternatively, when a radical or modied radical neck dissection is performed with
resection of the sternocleidomastoid muscle, a vastus lateralis muscle ap based off
perforators from the distal pedicle can also be used with a skin graft to provide skin
coverage (Fig.8.3). To bolster the pharyngeal repair, the fascia can be wrapped
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