Download PDF
J Reconstr Microsurg 2014; 30(06): 397-404
DOI: 10.1055/s-0034-1376532
Original Article WSRM 2013 Scientific Paper
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Transaxillary Thoracodorsal Artery Perforator Flap: A Versatile New Technique for Hypopharyngeal Reconstruction

Ayman Abdel-Wahab Amin
1   Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
,
Mohammed Rifaat
1   Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
,
Mohamed Ahmed Ellabban
2   Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School, Ismailia, Egypt
,
Mohamed Zedan
1   Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
,
Mohamed Kamel
1   Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
,
Mahmoud Bassiouny
1   Department of Surgical Oncology, National Cancer Institute, Cairo, Egypt
› Author Affiliations
Further Information

Publication History

04 March 2014

10 March 2014

Publication Date:
23 June 2014 (online)

    Permissions and Reprints

Abstract

Introduction Reconstruction of the hypopharynx and cervical esophagus after tumor resection remains a challenging problem. Different techniques of reconstruction have been described for such defects. Although free flap reconstruction, including jejunum and fasciocutaneous flaps, has gained popularity for this complex defect, regional flaps are still in use worldwide.

Patients and Methods We present our experience using the pedicled thoracodorsal artery perforator (TDAP) flap whereby only a small cuff of latissimus dorsi muscle around the perforators is harvested. The remaining muscle with its nerve supply is preserved. The flap is delivered to the neck through the cervicoaxillary tunnel. It was used as a complete tube in six patients and with an additional attached skin island for reconstruction of the neck skin in another four patients.

Results A total of 11 TDAP flaps were used for reconstruction in 10 patients. All flaps survived except in one patient who suffered from a complete flap loss. This was salvaged by another TDAP flap from the contralateral side. Partial sloughing of the outer part of the pedicled TDAP occurred in one other patient. Pharyngeal fistulas developed in another two patients and eventually healed spontaneously. All patients resumed an oral diet within 2 weeks except two with fistulas. All patients resumed their shoulder active range of motion within 3 weeks.

Conclusion The transaxillary TDAP flap is an ideal technique for hypopharyngeal reconstruction. It offers the advantages of free fasciocutaneous flaps, has a wide arc of rotation, a relatively larger flap dimension, a reliable vascular pedicle, and acceptable donor site morbidity.

Keywords

thoracodorsal artery flap - hypopharynx - transaxillary
 

  • References

  • 1 Wang HW, Chu PY, Kuo KT , et al. A reappraisal of surgical management for squamous cell carcinoma in the pharyngoesophageal junction. J Surg Oncol 2006; 93 (6) 468-476
    CrossrefPubMedGoogle Scholar
  • 2 Takes RP, Strojan P, Silver CE , et al; International Head and Neck Scientific Group. Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery. Head Neck 2012; 34 (2) 270-281
    CrossrefPubMedGoogle Scholar
  • 3 Pignon JP, Bourhis J, Domenge C, Designé L. Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-NC Collaborative Group. Meta-Analysis of Chemotherapy on Head and Neck Cancer. Lancet 2000; 355 (9208) 949-955
    CrossrefPubMedGoogle Scholar
  • 4 Adelstein DJ, Li Y, Adams GL , et al. An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer. J Clin Oncol 2003; 21 (1) 92-98
    CrossrefPubMedGoogle Scholar
  • 5 Richmon JD, Brumund KT. Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (4) 208-212
    CrossrefPubMedGoogle Scholar
  • 6 Disa JJ, Pusic AL, Hidalgo DA, Cordeiro PG. Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast Reconstr Surg 2003; 111 (2) 652-660 , discussion 661–663
    CrossrefPubMedGoogle Scholar
  • 7 Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg 2005; 116 (7) 1845-1855
    CrossrefPubMedGoogle Scholar
  • 8 Seidenberg B, Hurwitt ES. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Surg Forum 1958; 9: 413-416
    PubMedGoogle Scholar
  • 9 Disa JJ, Pusic AL, Mehrara BJ. Reconstruction of the hypopharynx with the free jejunum transfer. J Surg Oncol 2006; 94 (6) 466-470
    CrossrefPubMedGoogle Scholar
  • 10 Giovanoli P, Frey M, Schmid S, Flury R. Free jejunum transfers for functional reconstruction after tumour resections in the oral cavity and the pharynx: changes of morphology and function. Microsurgery 1996; 17 (10) 535-544
    CrossrefPubMedGoogle Scholar
  • 11 Kornfehl J. Autotransplanted jejunum in head and neck cancer. Eur J Cancer B Oral Oncol 1994; 30B (1) 16-22
    PubMedGoogle Scholar
  • 12 Cordeiro PG, Shah K, Santamaria E, Gollub MJ, Singh B, Shah JP. Barium swallows after free jejunal transfer: should they be performed routinely?. Plast Reconstr Surg 1999; 103 (4) 1167-1175
    CrossrefPubMedGoogle Scholar
  • 13 Schusterman MA, Shestak K, de Vries EJ , et al. Reconstruction of the cervical esophagus: free jejunal transfer versus gastric pull-up. Plast Reconstr Surg 1990; 85 (1) 16-21
    CrossrefPubMedGoogle Scholar
  • 14 Coleman III JJ, Searles Jr JM, Hester TR , et al. Ten years experience with the free jejunal autograft. Am J Surg 1987; 154 (4) 394-398
    CrossrefPubMedGoogle Scholar
  • 15 Amin AA, Bassiouny M, Elsebai H , et al. Fasciocutaneous free flaps for hypopharyngeal reconstruction. J Reconstr Microsurg 2002; 18 (1) 1-5
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995; 96 (7) 1608-1614
    CrossrefPubMedGoogle Scholar
  • 17 Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, Dupin CL. The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004; 114 (1) 32-41 , discussion 42–43
    CrossrefPubMedGoogle Scholar
  • 18 Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg 2003; 51 (1) 23-29
    CrossrefPubMedGoogle Scholar
  • 19 Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P, Monstrey S. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008; 121 (5) 1632-1641
    PubMedGoogle Scholar
  • 20 Spyropoulou GA, Lin PY, Chien CY, Kuo YR, Jeng SF. Reconstruction of the hypopharynx with the anterolateral thigh flap: defect classification, method, tips, and outcomes. Plast Reconstr Surg 2011; 127 (1) 161-172
    CrossrefPubMedGoogle Scholar
  • 21 McConnel FM. Analysis of pressure generation and bolus transit during pharyngeal swallowing. Laryngoscope 1988; 98 (1) 71-78
    PubMedGoogle Scholar
  • 22 Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial forearm flap. Clin Plast Surg 1994; 21 (1) 137-147
    PubMedGoogle Scholar
  • 23 Carlson GW, Schusterman MA, Guillamondegui OM. Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience. Ann Plast Surg 1992; 29 (5) 408-412
    CrossrefPubMedGoogle Scholar
  • 24 Chana JS, Wei FC. A review of the advantages of the anterolateral thigh flap in head and neck reconstruction. Br J Plast Surg 2004; 57 (7) 603-609
    CrossrefPubMedGoogle Scholar
  • 25 Valentini V, Cassoni A, Marianetti TM , et al. Diabetes as main risk factor in head and neck reconstructive surgery with free flaps. J Craniofac Surg 2008; 19 (4) 1080-1084
    CrossrefPubMedGoogle Scholar
  • 26 Suh JD, Sercarz JA, Abemayor E , et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 2004; 130 (8) 962-966
    CrossrefPubMedGoogle Scholar
  • 27 McCrory AL, Magnuson JS. Free tissue transfer versus pedicled flap in head and neck reconstruction. Laryngoscope 2002; 112 (12) 2161-2165
    CrossrefPubMedGoogle Scholar
  • 28 Woods JE. Reconstruction in head and neck cancer: a place for conservatism. Ann Plast Surg 1987; 18 (3) 209-211
    CrossrefPubMedGoogle Scholar
  • 29 Kim EK, Evangelista M, Evans GR. Use of free tissue transfers in head and neck reconstruction. J Craniofac Surg 2008; 19 (6) 1577-1582
    CrossrefPubMedGoogle Scholar
  • 30 Demirtas Y, Yagmur C, Kelahmetoglu O, Demir A, Guneren E. Transaxillary-subclavian transfer of pedicled latissimus dorsi musculocutaneous flap to head and neck region. J Craniofac Surg 2010; 21 (3) 771-775
    CrossrefPubMedGoogle Scholar
  • 31 Quillen CG, Shearin Jr JC, Georgiade NG. Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area: case report. Plast Reconstr Surg 1978; 62 (1) 113-117
    CrossrefPubMedGoogle Scholar
  • 32 Quillen CG. Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast Reconstr Surg 1979; 63 (5) 664-670
    CrossrefPubMedGoogle Scholar
  • 33 Hayden RE, Kirby SD, Deschler DG. Technical modifications of the latissimus dorsi pedicled flap to increase versatility and viability. Laryngoscope 2000; 110 (3 Pt 1) 352-357
    CrossrefPubMedGoogle Scholar
  • 34 Hamdi M, Decorte T, Demuynck M , et al. Shoulder function after harvesting a thoracodorsal artery perforator flap. Plast Reconstr Surg 2008; 122 (4) 1111-1117 , discussion 1118–1119
    CrossrefPubMedGoogle Scholar
  • 35 Schwabegger A, Ninković M, Brenner E, Anderl H. Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: observations on cause and prevention. Ann Plast Surg 1997; 38 (6) 594-597
    CrossrefPubMedGoogle Scholar
  • 36 Spinelli HM, Fink JA, Muzaffar AR. The latissimus dorsi perforator-based fasciocutaneous flap. Ann Plast Surg 1996; 37 (5) 500-506
    CrossrefPubMedGoogle Scholar