Ann Thorac Surg 2006;81:1090-1094
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Platysma Myocutaneous Flap for Patch Stricturoplasty in Relieving Short and Benign Cervical Esophageal Stricture
Yi-Dan Lin, MD,
Yao-Guang Jiang, MD
*
,
Ru-Wen Wang, MD,
Tai-Qian Gong, MD,
Jing-Hai Zhou, MD
Thoracic Surgery Department, Daping Hospital, Third Military Medical University, Chongqing City, China
Accepted for publication September 1, 2005.
* Address correspondence to Dr Jiang, Thoracic Surgery Department, Daping Hospital, Third Military Medical University, Changjiang Branch St, 10, Yuzhong District, Chongqing City, 400042 PR China (Email: stilldaniel{at}yahoo.com.cn).
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Abstract
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BACKGROUND: The purpose of this study is to introduce the use of a single-staged and laterally based platysma myocutaneous flap in patch stricturoplasty for relieving short and benign cervical esophageal stricture.
METHODS: Medical records were reviewed for 28 patients undergoing platysma myocutaneous flap for patch stricturoplasty in covering and widening short and benign cervical esophageal stricture in our department during the period between April 1990 and January 2004. The length of follow-up ranged from 4 months to 10 years with an average of 5 years. The surgical technique was described and the follow-up data was analyzed.
RESULTS: There were no operation deaths and all flaps survived without any necrosis. Anastomosis leakage developed in three cases (ie, two that were small and healed spontaneously after cervical drainage, whereas the third needed surgical revision). Re-stenosis occurred between the transposed flap and the gullet in two cases, one of which was relieved by repeated esophageal dilations and the other one was resolved by reoperation. No ulceration or carcinogenesis was discovered in the skin paddle during the time of follow-up. Pathologic analysis showed that the keratin layer of the skin paddle became thinner but was still arranged in the same structure as that of the normal skin. At the end of the follow-up, all 28 patients gained body weight on a regular oral diet.
CONCLUSIONS: Platysma myocutaneous flap can be accomplished in a single stage owning many advantages in comparison with other flaps for patch stricturoplasty in relieving the short and benign cervical esophageal stricture (ie, it is closer to the recipient site, thinner, pliable, and reliable).
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Introduction
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Benign esophageal stricture may result from an anastomotic stenosis after a colon interposition or a gastric pull-up, a vascular insufficiency of the transferred gut, or it may just be a simple esophageal stricture as a result of scarred constriction after an esophageal trauma, such as a caustic injury, a penetrating esophageal wound, and so on. The majority of such strictures can be successfully managed through conservative methods such as esophageal dilation or laser lysis. However, sometimes an intensive esophageal stricture may need surgical intervention. Stomach pull-up, colon bypass, and free jejunal flap [1] cannot always be applied as they may have already been used in a prior operation. Compared with visceral transposition, patch stricturoplasty, as an ideal option for relieving a short and benign cervical esophageal stricture, has been well established as a result of its convenience, less trauma, and shorter operation time. Tissue applied as a patch in widening the esophageal stricture varied as the staged flap, the myocutaneous flap, and the free flap [2]. Wookey's [3] cervical skin flap and Bakamjian's [4] deltopectoral flap are each a multi-stage flap accompanied with a high incidence of complications. The pectoralis major myocutaneous flap [5] and the latissimus dorsi myocutaneous flap [6] are each a single-staged flap with adequate blood supply, but each yields too much bulk and leads to a high incidence of donor-site morbidity and continued aspiration. Free flaps, such as the forearm flap [7–9], are time consuming and prone to donor-site morbidity in needing microvascular anastomosis [1]. This article introduces our pioneer use of the platysma myocutaneous flap (PMCF) as a single-stage and pliable flap in patch stricturoplasty for relieving a short and benign cervical esophageal stricture beginning in April 1990.
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Patients and Methods
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Medical records were reviewed for every patient admitted to Daping Hospital because of cervical esophageal stricture from April 1990 to January 2004. Operative death was defined as any death within 30 days after operation or during hospitalization. The function of swallowing would be regarded as well when the subject experienced a fluent swallowing of regular diet and the barium meal study showed no hampering of bolus transfer through the reconstructed gullet. Follow-up, obtained by review of office records or telephone interview, was completed through January 2005.
Preoperative evaluation included upper gastrointestinal endoscopy, barium meal, and iodine contrast study. Attempts were made to explore the patency and integrity of the larynx, pharynx, and esophagus.
The operation was performed under general endotracheal anesthesia. The patient was placed in a supine position with the head turned to the right and the back slightly elevated with a small pillow. The cervical incision was made along the anterior border of the left sternocleidomastoid muscle or by reopening a previous cervical incision (Fig 1A). To facilitate exploration, the sternocleidomastoid muscle was laterally retracted together with the common carotid sheath. Blunt dissection of the esophagus was extended downward along the prevertebral space. Then the stricture site was explored by tracing along the esophagus. If the stricture was badly severe, a tracheal tube was induced through the oropharynx downward to the stricture site as an indicator for anatomic marking. A cervical coloesophageal or gastroesophageal anastomotic stenosis was managed in the following way: the anastomotic stenosis was opened longitudinally through the stenosis and extended in approximately 1.0 cm both proximately into the normal-caliber esophageal lumen and distally into the normal-caliber colonic-gastric lumen (Fig 1B). Thus an elliptical patchy defect would be resulted not only on the esophageal wall but also on a portion of the proximal colon and stomach. In this circumstance esophageal stricturoplasty involved esophagoplasty concomitantly with colo-gastroplasty. A simple esophageal stricture was managed in the following way: after the stricture site was identified, an esophagotomy was performed longitudinally through the stricture site and extended in approximately 1.0 cm into the normal-caliber lumen both proximately and distally. In this way an elliptical patchy defect would be resulted on the wall of the cervical esophagus or even the hypopharynx if it was very close to the stricture site. The ipsilateral flap was harvested only after it was confirmed that the resulted elliptical patchy defect (usually 3 
4 cm in length) could be managed with a PMCF reconstruction. The skin paddle of the PMCF was designed in a 6 7 cm x 4 5 cm rectangular shape overlying the inferior aspect of the platysma (Fig 1A). The making of the PMCF anterior margin could be concomitantly accomplished when opening the cervical incision. On each of site of the three margins of the PMCF (ie, [1] the anterior, [2] the superior, and [3] the inferior margins), the full-thickness of the skin and the whole layer of the underlying platysma were completely dissected. To protect the competence of the underlying platysma pedicle when making the posterior incisal margin of PMCF, the dissection was mandatory to perform only within the subcutaneous layer with an anterior dissociation of 1.5 cm. A laterally based, thin and pliable PMCF was thus created, applying the underlying platysma both as its constructive component and blood supply pedicle (Fig 1C). Its length and width were trimmed to a slightly lager size than that of the elliptical defect. This flap was rotated forward after its anterior margin had been anchored to the left rim of the elliptical defect (Fig 1D) so that the skin paddle was facing into the esophageal lumen (Fig 1E). Then the PMCF was sewn in place to the elliptical defect using full-layered interrupted sutures with No. 4 nonabsorbable silk lines. For gastrointestinal decompression and the early nasal feeding, a nasogastric tube was directed into the stomach under direct vision before the patch closure was completed. Finally the cervical incision was sutured appositionally after a Penrose drain was placed each behind the anastomotic site and into the lower posterior triangle of the neck. The drainage positioned in the lower posterior triangle was removed on the third postoperative day, whereas the other one in the anastomotic site was maintained for an additional week.
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Fig 1. Photographs of a patch stricturoplasty using the platysma myocutaneous flap (PMCF) in the treatment of a cervical gastroesophageal anastomotic stenosis. (A) Preoperative schematic marker indicating incision and the PMCF. (1) The incision would be made along the anterior border of the sternocleidomastoid muscle or by reopening a previous cervical incision, and in doing so the anterior margin of the PMCF would form concomitantly. (2) The superior, (3) the inferior, and (4) the posterior margins of the rectangular shaped the PMCF overlying the inferior aspect of the platysma. (B) The gastroesophageal anastomotic stenosis was opened longitudinally through the stenosis and extended in about 1.0 cm both proximately into (1) the normal-caliber esophageal lumen and distally into (2) the normal-caliber gastric lumen. (3) The cutting edges of the elliptical defect, (4) the anterior margin of the PMCF, and (5) the thyroid gland. (C) The making of a PMCF. The skin of the PMCF was designed in a 6 7 cm x 4 5 cm rectangular shape, slightly larger in size than that of the elliptical defect, overlying the inferior aspect of the platysma. Completely cutting off the full-thickness of the skin and the whole layer of the underlying platysma on each site of the three margins, (1) the anterior, (2) the superior, and (3) the inferior PMCF margins each contained both a skin part and a platysma part. However, (4) the posterior incise margin was constructed only by the skin part because the dissection and dissociation there were mandatory to perform just in the subcutaneous layer for avoiding any damage to the competence of (5) the underlying platysma pedicle. (6) The left sternocleidomastoid muscle. (D) The anterior PMCF margin was anchored to the left incise edge of the elliptical defect using full-layered interrupted sutures with (1) No. 4 nonabsorbable silk lines. (2) The right incisal edge of the elliptical defect, (3) the gastric lumen, and (4) the gastric tube. (E) The PMCF was rotated forward so that (1) the skin paddle was facing into the esophageal and (2) the gastric lumen. The PMCF was sewn in place to (3) the incisal edges of the elliptical defect using full-layered interrupted sutures with (4) No. 4 nonabsorbable silk lines.
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Tube feeding usually began on the third postoperative day, and oral intake was forbidden until an iodine contrast study had demonstrated an intact anastomosis 2 weeks later. The diet was then advanced from liquid to semi-liquid and finally to a regular diet.
During follow-up, all patients were inquired in regard to body weight, any dysphagia, type of diet, and need for nutritional supplements. Barium meal study and endoscopy were performed if possible.
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Results
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Twenty-eight cases were identified applying the PMCF for plastic surgery in covering and widening the cervical esophageal stricture. Among them there were 20 male and 8 female patients (mean age, 33 ± 17 years; range, 3 to 67 years). The causes of cervical esophageal stricture included an anastomotic stenosis after colon interposition due to a caustic injury in 20 patients (involving 13 patients transferred to our hospital), an anastomotic stenosis after gastric pull-up due to the upper esophageal carcinoma in 2 patients, a scarred constriction after caustic ingestion in 3 patients, a scarred constriction after knife-causing penetrating esophageal wound in 1 patient, and an iatrogenic perforation in the last 2 patients. The anastomotic stenosis occurred 2 25 months (mean, 3.8 ± 10 months) after the primary operation.
The time interval from dysphagia to patch stricturoplasty intervention ranged from 2 months to 15 years, with an average of 12 months. A preoperative barium meal and iodine contrast study showed that all of the strictures were located in the cervical area with a length ranging from 3.5 to 4.5 cm, and a diameter varying from 0.3 to 0.5 cm in 6 patients, less than 0.3 cm in 17 patients, and an unmeasurable one in the other 5 patients evidenced by the complete occlusion of the passage of barium and iodine in the stricture site. During the preoperative period, 23 patients could keep an oral intake of liquid diet with the help of repeated esophageal dilatations (3 16 times) including 1 patient having accepted an implantation of an expandable metal stent (EMS) in another hospital after dilatations. In spite of these conservative treatments, all 23 patients were still tortured by a mild to a moderate dysphagia and suffered weight loss (mean, 3.7 ± 2.0 kg; range, 1.5 5.7 kg), and 3 of these patients suffered repeated aspiration pneumonia, whereas the other 5 patients who suffered from a complete cervical esophageal occlusion underwent gastrostomy or jejunostomy for enteral nutrition support. There was no aspiration pneumonia that occurred in these 5 patients, whose body weight remained unchanged in 2 patients, increased at 2.4 kg in 1 patient, and decreased approximately 2.0 kg in the other 2 patients.
The PMCF was applied for patch stricturoplasty in all 28 patients. There was no operative death. All flaps survived without any necrosis. Early leakage at the anastomotic site occurred in 1 patient on postoperative day 5, and late leakage was seen in 2 patients on approximately postoperative day 21. All of the patients spontaneously healed with the assistance of cervical drainage for approximately 1 month. Aspiration pneumonia combined with transient hoarseness occurring in 2 patients was ascribed mostly to the recurrent nerve damage-causing glottic dysfunction in the early postoperative stage.
The length of follow-up ranged from 4 months to 10 years with an average of 5 years. The movement of swallowing functioned well after operation in 26 patients. Two patients had an anastomotic re-stenosis develop in the second and sixth postoperative months, respectively; one of the patients was successfully cured by repeated dilitations, and the other accepted another simple esophagoplasty at last. One of the patients with esophageal carcinoma died of malignant metastasis 18 months after the operation, and the other patient is still surviving and maintaining fluent swallowing. By manometric study the motor disharmony in the reconstructed segment of the PMCF was evident in that a lower pressure zone was identified in comparison with the gullet either proximal or distal to the PMCF segment. Little peristalsis was discovered in the reconstructed segment of the PMCF through the barium and iodine contrast study, and a mild bulge was found to gradually form ever since the first postoperative month. However, none of these conditions was found to affect the passage of bolus through the reconstructed segment (Fig 2). There was no postoperative aspiration pneumonia in this series. Endoscopy was accomplished in 16 patients. During the first 6 postoperative months the skin paddle of the PMCF seemed ruddy in color, gradually becoming gray and white later in time. Neither ulcerations nor carcinogenesis was discovered in the skin paddle during the time of follow-up. Endoscopic biopsy on the flap was obtained in 5 patients. The pathologic analysis showed that the keratin layer of the skin paddle became thinner, but it was still arranged in the same structure as that of the normal skin. At the end of the follow-up, all 28 patients gained body weight on a regular oral diet.
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Fig 2. Preoperative and postoperative photographs of barium meal study on a patient suffering a scarred constriction after caustic cervical esophageal injury. Left: an intensive caustic stricture was identified in the cervical esophagus. Middle: the patch stricturoplasty was performed primarily applying the PMCF in relieving the short and benign cervical esophageal stricture. However, from the first postoperative month a mild bulge was found to gradually form in the reconstructed gullet (arrow). Nevertheless the bolus transfer was not affected. Right: a smooth passage of barium meal through the reconstructed gullet 4 years after the operation (arrow).
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Comment
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The use of myocutaneous flap in reconstructive plastic surgery has been accepted as a reliable method ever since 1977 when McCraw and colleagues [10] confirmed the contribution of the muscle to the blood supply of its overlying skin paddle. From then on, various myocutaneous flaps have been described for filling defects or covering bone grafts or other deep repairs. The PMCF was first introduced by Futrell [11] in 1978 and has been mainly used in the surgical reconstruction of the neck and maxillofacial defect ever since. Anatomic study [12, 13] reveals that the platysma is a unique muscle lying with the subcutaneous tissue. The blood supply to PMCF involves the submental artery, the facial artery, the superior thyroid artery, the occipital artery, the posterior auricular artery, and the transverse cervical artery. In addition, it receives numerous extremely fine muscular perforators from the sternocleidomastoid, trapeziums, and strap muscles [14, 15]. Its venous flows are mainly collected into the internal jugular vein and the submental vein. Part or full flap loss is a severe complication in plastic surgery, which is reported to occur in approximately 40% of patients mainly due to the destruction of the vascular supply provided by the facial artery [16, 17], or the submental artery [18], or the venous drainage [13]. The precise anatomic study on the blood supply of the PMCF and its closer donor site inspired us to re-design a rectangular PMCF to cover the cervical esophageal defect. During the elevation of our revised Futrell's PMCF, all of the vital arteries and veins are maintained except the superior thyroid artery, which might be ligated when exploring the cervical esophagus. Additional key factors for flap survival are the avoidance of using any electronic coagulator for hemostasis, and the resection of the distal limb of the left sternocleidomastoid muscle is sometimes necessary to release the tension on the platysma pedicle. All 28 flaps survived without any loss and there was neither ulceration nor carcinogenesis discovered in the skin paddle during the time of follow-up.
The transposed PMCF remains innervated by the nerves from the platysma, but it cannot motivate any peristalsis coincident to the swallowing action. Motor disharmony of the PMCF segment was evident in the test of manometry in that a lower pressure zone was identified in comparison with the part of the gullet either proximal or distal to the PMCF segment. Therefore the bolus passage at the reconstructed gullet occurs mainly by the tongue driving force as well as the gravity. Compared with a bulky flap such as the pectoralis major flap or the latissimus dorsi myocutaneous flap, the PMCF is thinner, softer, and more pliable. In addition, the skin paddle is well keratinized and hairless; therefore there is almost no resistance to bolus transfer that can be produced in the reconstructed gullet. According to these characteristics of the PMCF, we therefore believe an improved swallowing kinetics can always be expected after PMCF transpose. However, as shown in our canine animal model [19], the bolus transfer may be hampered by the regeneration of the shaved hair on the raised flap. So the hair follicles in the neck skin must be considered when using this technique in the male Caucasian population.
The incidence of flap leakage and re-stenosis in this series is 10.7% (3 of 28) and 7.1% (2 of 28), respectively, which is lower than that of using other flaps such as the pectoralis major myocutaneous flap [20] and the free skin flap [21]. Until now, the occurrence of flap leakage or re-stenosis could not be totally avoided because of the differential healing process existing between the myocutaneous flap and the esophagus. Nevertheless, a careful operative design may do some compensation. In relieving the tension at the anastomotic site we prefer to tailor a PMCF in a relatively larger size than that of the elliptical defect, and then perform the anastomosis in place with full-layered interrupted sutures. The blood supply to the anastomotic site is abundant in applying the inferior platysma not only as a constructive component but also as a blood supply pedicle. Early enteral nutrition support can be achieved through a nasogastric tube feeding on the third postoperative day because the whole operation procedure can be accomplished in just a localized area of the neck without any interference into the abdominal cavity. Nevertheless, oral intake should be forbidden until postoperative day 14, when the integrity of the gullet has been proven by the esophagogram.
A large amount of granulomatous tissues were found at the proximal end of the expandable metal stent, occluding the esophageal lumen in 1 of our patients who received an esophageal stent in another hospital. Although the expandable metal stent is sometimes applied in the treatment of the benign esophageal stricture [22], it is rarely indicated in our department for fear of the related high morbidity of the new stricture formation [23, 24], which is believed to be due to fibrosis from mechanical injury to the esophageal wall at the proximal or distal ends of the stent, or both. Mucosal hyperplasia narrows the lumen through overgrowth at the ends or ingrowth through the wire mesh if an uncovered stent is used. Thus we believe that expanding the indications for esophageal stenting to include benign stricture is not justified at the present time. However, improvement in materials, such as a biodegradable or removable stent may thoroughly change this concept in the future.
In summary, the PMCF can be used as a patch for covering short and benign cervical esophageal defects. It has been proven to be direct, pliable, and closer primarily to the recipient site.
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Footnotes
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The first two authors, Drs Lin and Jiang, should both be regarded as joint first authors.
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References
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Abstract
Introduction
