Dysphagia after pharyngolaryngeal cancer surgery. Part II: Implications for reconstructive procedures.

In the base of the tongue region, reconstructive procedures have to provide more bulky-tissue coverage (i.e., myocutaneous flaps) in order to avoid cranial release of pressure and to bring about swallowing initiation. Resections of the pharyngoesophageal (PE) segment cause circular defects, always affecting the sphincter and necessarily relaxation, thus reducing the hypopharyngeal suction pump. The resistance to bolus flow, therefore, is generally increased but can be compensated by a stronger tongue driving force. In addition to the functional obstruction, special attention is called to the growing lumen discontinuity between the wide pharynx and the narrow esophagus. Plastic reconstructions, therefore, have to compensate for different lumina distally. Following ablative surgery in the upper esophageal sphincter region, a softer and smoother tissue coverage is warranted in order to facilitate bolus transfer to a passive bolus flow if necessary. For that purpose, a new myofascial pectoralis flap was designed based on morphometric investigations and postmortal selective injection studies. In this flap, the bulky muscle mass is separated from just a vascularized, thin fascia-muscle layer. The donor site is covered with the remaining bulky muscle-skin complex left intact. The fascial flap covers defects where a soft lining is required and replaces the PE segment as a tubed neopharynx. Histologic specimens show a reepithelization with local mucous membrane from the anastomotic site to the fascial surface. The resistance to bolus flow is reduced, thus alleviating the tongue driving force, which is increased for compensation in any case.