Triple Pedicled Flap Reconstruction for the Pharyngeal Necrosis: One-stage Suture of the Deltoid-pectoral Flap Harvesting Area

The patient was a 71-year-old male with hypopharyngeal carcinoma who underwent right-sided neck dissection for lymph node metastasis, adjuvant radiotherapy (70 Gy), and cisplatin chemotherapy, he developed neck inflammation with evidence of free air on computed tomography and subcutaneous fistula formation on laryngoscopy. After total laryngectomy, bilateral neck vessels were obscured by scar tissue secondary to radiotherapy and chronic inflammation. Pedicled pectoralis major (PM) flap was favored for reconstruction. A 20×7 cm PM flap was harvested from the right thoracic region, and the muscle body was harvested caudally to obliterate the dead space in the neck. After complete circumferential suturing, the dead space in the cervical region was filled by suturing the PM muscle body to the exposed cervical spine. A deltoid-pectoral (DP) flap was harvested from the right side and used to create the cephalic aspect of the permanent tracheostoma. In addition, a large right anterior pectoral flap was created lateral to the PM muscle, meticulously preserving the perforating intercostal artery branch during flap elevation. Lastly, the DP flap harvest site and neck defect were temporary. This case report presents a novel technique for laryngeal necrosis reconstruction using a combination of PM, DP, and anterior thoracic flaps. The approach achieved total suture closure of the DP flap harvest site, offering significant advantages. This technique should be considered in patients undergoing reconstruction with DP flaps.