Strategic four-dimensional reconstruction in cervical exenteration: A preventive reconstructive framework for anticipating and managing defects.

Abstract

Anterior mediastinal tracheostomy (AMTr) following cervical exenteration creates massive, three-dimensional defects with high morbidity, particularly catastrophic great vessel rupture. To mitigate these risks, we developed a hierarchical conceptual framework categorizing reconstructive objectives into primary (immediate form and functional restoration), secondary (intraoperative complication prevention), and tertiary (postoperative functional and structural maintenance) goals. We retrospectively reviewed 9 patients (mean age, 66.7 years) who underwent cervical exenteration and AMTr for advanced cervicothoracic malignancies (2012-2022). Reconstructions followed our proposed roadmap: alimentary continuity was restored via free jejunal flap (FJF) or gastric pull-up. Airway exteriorization and dead-space obliteration were achieved via inferolateral tracheal transposition supported by pectoralis major musculocutaneous (PMMC) or deltopectoral flaps. Primary goals (airway and alimentary restoration) were achieved in a single stage in 88.9% (8/9) of patients. Secondary goals (preventing great vessel rupture and catastrophic mediastinitis) were met in 100% (9/9), demonstrating the protective "pillowing" efficacy of the FJF mesentery and the PMMC muscle wrap. Tertiary goals were met in 77.8% (7/9) of cases; a single case of postoperative flail chest demonstrated that thinner fasciocutaneous flaps provide insufficient volume for massive defects, thereby dictating a strategic preference for the PMMC flap. A structured conceptual framework simplifies complex post-exenteration reconstruction. Integrating an FJF for alimentary restoration with a PMMC flap obliterates mediastinal dead space and, crucially, supports a safe, tension-free tracheostoma. This approach effectively mitigates the severe morbidity and vascular risks of AMTr.