PHARYNGEAL RECONSTRUCTION WITH THE APRON PLATYSMA MYOCUTANEOUS FLAP RICARDO BERNALDEZ, MD, MARIA A. CERDEIRA, MD, JAVIER GAVILAN, MD Pharyngolaryngeal tumors show considerable submu- cosal spread and are often more extensive than they clin- ically appear . Following pharyngolaryngectomy, it is not unusual to deal with insufficient hypopharyngeal tis- sue for simple closure of the defect. The ideal method for pharyngeal reconstruction after ablative surgery should be simple, efficient, and fast, with minimal mor- bidity. Furthermore, tumor resection should not be con- ditioned by reconstructive requirements. Most commonly used graft and flap techniques are dif- ficult and time-consuming procedures that must be per- formed at the end of a long operation. This may pro- duce desperate attempts to restore hypopharyngeal con- tinuity by simple approximation of the remaining mucosa. The result of suturing the hypopharynx under tension is a constricted pharyngeal lumen predisposing to pharyngeal stenosis with wound breakdown and pharyngocutaneous fistula. Pharyngeal stenosis is a se- rious complication requiring either lifelong fluid nutrition or ongoing pharyngeal dilations. In addition, esopha- geal speech rehabilitation is very compromised by pha- ryngeal stenosis. The apron platysma myocutaneous flap, popularized by Herrmann, is a fast and simple one-stage reconstruc- tive method, with no added morbidity to the primary treatment. It allows a wide pharyngeal closure in pa- tients with only a narrow strip of pharyngeal mucosa remaining after ablative surgery. SURGICAL TECHNIQUE The operation begins with the classic apron flap. The incision starts at the tip of the mastoid process and ex- tends inferiorly along the posterior border of the sterno- cleidomastoid muscle to a level just below the cricoid arch. From this point, the incision is extended postero- superiorly along the posterior face of the sternocleido- mastoid muscle to the contralateral mastoid process. When neck dissection is to be combined with the primary treatment, a lateral supraclavicular extension provides adequate exposure to the posterior triangle of the neck. The skin flaps are raised deep to the platysma muscle. When functional neck dissection is planned, the superfi- ciallayer of the cervical fascia is not included in the flap From the Department of Otorhinolaryngology, la Paz Hospital, Au- tonomous University, Madrid, Spain. Address reprint requests to Ricardo Bernaldez, MD, Servicio de ORl , Hospital la Paz, Paseo de la Castellana, 261, 28046 - Madrid, Spain. Copyright © 1993 by W.B. Saunders Company 1043·1810/93/0404-0012$05.00/0 becau se it will be removed with the fibrofatty tissue of the neck, as in any other functional neck dissection. When functional neck dissection is not part of the treatment, the .r superficial layer of the cervical fascia is also included in the apron flap. The flap is developed superiorly in a standard fashion until it is below the level of the horizon- tal ramus of the mandible. The apron flap, including skin, subcutaneous tissue, and platysma muscle, is now ready for pharyngeal reconstruction. Once the neck dissection and tumor removal have been completed, the lateral extension of the hypopharyngeal defect is exposed with traction sutures on either end . All irregular margins of the pharyngeal mucosa are re- moved, especially those areas that appear to have an in- sufficient blood supply. The mucosal edge of the vallec- ula and the base of the tongue at the anterior hypopha- ryngeal defect are sutured to the inner surface of the superior base of the apron platysma flap (Fig lA) . Then both sides of the lateral edge of the remaining strip of hypopharyngeal mucosa are sutured with interrupted or continuous 3-0 absorbable polyglycolic acid or polyethyl- ene glycol sutures to the inner surface of the apron platysma flap (Fig IB). These sutures create the lateral borders of the new hypopharynx, leaving at least a 3-cm- wide inner surface of apron flap to serve as anterior hy- popharyngeal wall. The sutures are then taken down- ward and medially to approximate the cut edge of the anterior wall of the lower hypopharynx or cervical esoph- agus to the inner surface of the apron platysma flap (Fig lC). A 2-cm inferior margin of apron platysma flap should be reserved to create the upper face of the trache- ostomy (Fig ID). A nasogastric feeding tube is inserted before comple- tion of the pharyngeal closure. Finally, the 'tracheo- stomy is constructed in the usual fashion and the skin is closed (Fig IE). Tube feeding is started on the first post- operative day and oral feeding begins on the tenth day . INDICATIONS AND ADVANTAGES This procedure may be used following major resections of the hypopharyn x. Tongue base resections, extensive pyriform sinus tumors, or postcricoid cancers very often result in insufficient tissue remaining for primary closure without compromising the pharyngeal lumen. In all these cases, the apron platysma flap is indicated. The apron platysma myocutaneous flap may be used in pa- tients in whom the anterolateral pharyngeal walls have been removed. A narrow strip of posterior hypopha- ryngeal mucosa (2 em) is the only requirement of this flap. The principal advantages of the apron platysma myo- cutaneous flap include easy accessibility, no extra time OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY. VOL 4, NO 4 (DEC), 1993 : PP 303-305 303