Long-term outcomes of microsurgical reconstruction for large tracheal defects

Laryngotracheal Reconstruction for Subglottic and Tracheal Stenosis

Laryngotracheal stenosis is the common endpoint for any process that results in the narrowing of the airway at the level of the glottis, subglottis, or trachea. Although endoscopic procedures are effective in opening the airway lumen, open resection and reconstruction can be necessary to reconstitute a functional airway. When resection and anastomosis are insufficient due to extensive length or location of the stenosis, autologous grafts can be used to expand the airway. Future directions in airway reconstruction include tissue engineering and allotransplantation.

Pre-epithelialized cryopreserved tracheal allograft for neo-trachea flap engineering

Background: Tracheal reconstruction presents a challenge because of the difficulty in maintaining the rigidity of the trachea to ensure an open lumen and in achieving an intact luminal lining that secretes mucus to protect against infection. Methods: On the basis of the finding that tracheal cartilage has immune privilege, researchers recently started subjecting tracheal allografts to "partial decellularization" (in which only the epithelium and its antigenicity are removed), rather than complete decellularization, to maintain the tracheal cartilage as an ideal scaffold for tracheal tissue engineering and reconstruction. In the present study, we combined a bioengineering approach and a cryopreservation technique to fabricate a neo-trachea using pre-epithelialized cryopreserved tracheal allograft (ReCTA). Results: Our findings in rat heterotopic and orthotopic implantation models confirmed that tracheal cartilage has sufficient mechanical properties to bear neck movement and compression; indicated that pre-epithelialization with respiratory epithelial cells can prevent fibrosis obliteration and maintain lumen/airway patency; and showed that a pedicled adipose tissue flap can be easily integrated with a tracheal construct to achieve neovascularization. Conclusion: ReCTA can be pre-epithelialized and pre-vascularized using a 2-stage bioengineering approach and thus provides a promising strategy for tracheal tissue engineering.

A novel classification of tracheal defects and the reconstruction strategies: A retrospective study based on 106 cases

Objective

The study aims to present a novel classification of tracheal defects and the corresponding reconstruction strategies.

Methods

The retrospective study was designed to analyze patients with diagnosed primary or secondary tracheal tumors from 1991 to 2020. Surgical techniques, complications and prognosis were reviewed. Airway status and patient outcomes were the principal follow-up measures. Tracheal defects were classified into two plane sizes (vertical (V) and horizontal (H) planes). Vertical defects were further categorized into three groups based on their tracheal ring numbers (V1, ≤ 5 rings; V2, 6-10 rings; and V3, > 10 rings). Tracheal defects with horizontal plane size H1 and H2 represent defects less and more than one-half the circumference of trachea. Thus, suitable reconstruction strategies were planned primarily based on "V" and "H" classifications. The reconstruction strategies performed were sleeve resection followed by an end-to-end anastomosis, window resection with sternocleidomastoid myoperiosteal flap reconstruction, defects conversion with rotation anastomosis, and modified tracheostomy with secondary flap reconstruction.

Results

A total of 106 patients diagnosed with tracheal defects were enrolled in the study, of whom 59 patients underwent sleeve resection followed by end-to-end anastomosis; 40 patients received window resection alongside sternocleidomastoid (SCM) myoperiosteal flap reconstruction; five patients received converting defects with rotation anastomosis and two patients underwent modified tracheostomy with secondary stage flap reconstruction. Lumen stenosis occurred in three V2H1 defect cases and were treated by a second reconstruction surgery. Iatrogenic unilateral recurrent laryngeal nerve paralysis occurred in two patients with the V3H2 defect type, who were treated by temporary tracheotomy and partial vocal cord resection and extubated successfully during follow-up. All 106 patients achieved airway patency with adequate laryngeal function at the end of follow-up. No anastomotic dehiscence or bleeding occurred in any patient postoperatively.

Conclusion

Though a significant number of multicenter studies concerning the reconstruction and classification of tracheal defects are needed, the study herein provides a novel classification of tracheal defects, which is primarily developed on the defect size. Therefore, the study might serve as a potential source for identifying suitable reconstruction strategies for practitioners.

Four-decade-old benign tracheomediastinal fistula

A 70-year-old male with a nagging cough of 40-year duration was evaluated and found to have a tracheomediastinal fistula. He gave history of rigid bronchoscopy 40 years back. He underwent successful resection of the fistula and was fully relieved of his symptom.

Biomimetic Trachea Engineering via a Modular Ring Strategy Based on Bone-Marrow Stem Cells and Atelocollagen for Use in Extensive Tracheal Reconstruction

The fabrication of biomimetic tracheas with a architecture of cartilaginous rings alternately interspersed between vascularized fibrous tissue (CRVFT) has the potential to perfectly recapitulate the normal tracheal structure and function. Herein, the development of a customized chondroitin-sulfate-incorporating type-II atelocollagen (COL II/CS) scaffold with excellent chondrogenic capacity and a type-I atelocollagen (COL I) scaffold to facilitate the formation of vascularized fibrous tissue is described. An efficient modular ring strategy is then adopted to develop a CRVFT-based biomimetic trachea. The in vitro engineering of cartilaginous rings is achieved via the recellularization of ring-shaped COL II/CS scaffolds using bone marrow stem cells as a mimetic for native cartilaginous ring tissue. A CRVFT-based trachea with biomimetic mechanical properties, composed of bionic biochemical components, is additionally successfully generated in vivo via the alternating stacking of cartilaginous rings and ring-shaped COL I scaffolds on a silicone pipe. The resultant biomimetic trachea with pedicled muscular flaps is used for extensive tracheal reconstruction and exhibits satisfactory therapeutic outcomes with structural and functional properties similar to those of native trachea. This is the first study to utilize stem cells for long-segmental tracheal cartilaginous regeneration and this represents a promising method for extensive tracheal reconstruction.

Vascularized Prelaminated Thermoplastic Bioabsorbable Scaffold in Tracheal Reconstruction

Successful tracheal reconstruction remains a challenging task for the reconstructive surgeon. A variety of techniques have been previously employed, using both autografts and allografts. The authors present a novel method for tracheal reconstruction utilizing a prelaminated fascial flap in conjunction with a bioabsorbable scaffold. Laryngoscope, 2021.

Anaplastic thyroid cancer with long-term survival with lenvatinib therapy and preservation of laryngeal function after one-stage reconstruction: A case report

Laryngotracheal reconstruction is performed to treat locally advanced thyroid carcinoma invading the larynx and/or trachea. The reconstructive technique varies. The present report describes the case of a 71-year-old female patient who underwent surgery for thyroid carcinoma involving the larynx. Reconstructive surgical techniques were employed to maintain laryngeal structure and function. An anterolateral thigh flap with free rib cartilage grafts was used to compensate for laryngeal defects. Although a temporary tracheal stoma was constructed, it closed spontaneously after decannulation. Therefore, one-stage laryngeal reconstruction was accomplished. Post-operative histopathological examination revealed focal anaplastic changes in the lesion, which mainly consisted of papillary components. Post-operative positron emission tomography/computed tomography indicated early recurrence in the left side of the neck. Therefore, lenvatinib was started as adjuvant therapy. Complete response was observed with lenvatinib therapy. The patient was alive and had good laryngeal function 26 months after the operation. One-stage laryngeal reconstruction can reduce burden and improve quality of life in patients with thyroid carcinoma involving the larynx. Lenvatinib may be useful for treating early recurrence of anaplastic thyroid carcinoma after reconstructive surgery with a free flap.

Successful reconstruction of an intrathoracic tracheal defect using a muscle flap and conchal cartilage graft

BACKGROUND

Malignant invasion of the respiratory tract is a common complication in advanced cases of esophageal carcinoma. Resection and reconstruction can be extremely challenging, particularly when the invasion is intrathoracic. A circumferential tracheal resection with direct tracheal closure or mediastinal tracheostomy is often performed, but the outcome is not always favorable, with high morbidity rates, loss of vocal function, and reduced quality of life.

METHODS

We present our experience in performing an intrathoracic tracheal reconstruction in which a conchal cartilage graft was used in combination with a pectoralis major muscle transposition.

RESULTS

This was successfully done following the noncircumferential resection of the intrathoracic trachea due to mural invasion by a metastatic lymph node of esophageal carcinoma.

CONCLUSIONS

We believe this report will contribute to the growing body of clinical expertise on procedures for intrathoracic tracheal reconstruction.

Surgical Management of Tracheal Invasion by Well-Differentiated Thyroid Cancer

Simple Summary

Tracheal invasion is a poor prognostic factor in well-differentiated thyroid cancer. Appropriate resection can improve the prognosis and maintain the patient’s quality of life. Shaving resection for superficial tracheal invasion is minimally invasive because it does not involve the tracheal lumen, despite the problematic risk of local recurrence. Window resection for tracheal mucosal and luminal invasion provides good tumor control and does not cause postoperative airway obstruction; however, the need for surgical closure of the tracheocutaneous fistula is a disadvantage of this method. Circumferential (sleeve) resection and end-to-end anastomosis are highly curative, but the risk of fatal complications, such as anastomosis dehiscence, is a concern.

Abstract

Well-differentiated thyroid carcinoma (WDTC) is a slow-growing cancer with a good prognosis, but may show extraglandular progression involving the invasion of tumor-adjacent tissues, such as the trachea, esophagus, and recurrent laryngeal nerve. Tracheal invasion by WDTC is infrequent. Since this condition is rare, relevant high-level evidence about it is lacking. Tracheal invasion by a WDTC has a negative impact on survival, with intraluminal tumor development constituting a worse prognostic factor than superficial tracheal invasion. In WDTC, curative resection is often feasible with a small safety margin, and complete resection can ensure a good prognosis. Despite its resectability, accurate knowledge of the tracheal and peritracheal anatomy and proper selection of surgical techniques are essential for complete resection. However, there is no standard guideline on surgical indications and the recommended procedure in trachea-invading WDTC. This review discusses the indications for radical resection and the three currently available major resection methods: shaving, window resection, and sleeve resection with end-to-end anastomosis. The review shows that the decision for radical resection should be based on the patient’s general condition, tumor status, expected survival duration, and the treating facility’s strengths and weaknesses.

Fabricating Flaps in the Forearm Prior to Tracheal Reconstruction

Background  The process of reconstruction of tracheal defects is complex and still not optimum. Options range from using staged reconstructions, combining flaps with autologous or alloplastic implants, as well as use of tissue-engineered constructs combined with vascularized tissues which are lined with cell cultures. Staged reconstructions using prelaminated epithelium, and prefabricated flaps, help in reconstruction of this complex structure. Prefabricating the flap at a different site allows for integration of the tissues prior to its transfer. Method  This article reports two patients planned for tracheal reconstruction for the purpose of advanced papillary carcinoma of the thyroid invading the trachea. Staged reconstruction using a prefabricated radial artery forearm flap (RAFF) and split rib cartilage was performed. In the second patient, a young girl, a similar construct of the RAFF, prelaminated with buccal mucosa, was performed. However, in the latter case, an intraoperative decision by the head and neck team to limit excision of the trachea sparing the mucosa was taken; the reconstruct in the forearm was redundant and needed to be discarded, replacing the defect with a free superficial circumflex iliac artery perforator (SCIP) flap. Result  At 3 years follow-up, both the patients are free of disease, with the construct serving its purpose in the older female.

Clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction

Background

Large or complex trachea defects often require some tissue to reconstruct, various flaps have been reported for reconstructing this defect. However, pedicled thoracoacromial artery perforator flap have not been reported in tracheal reconstruction. Therefore, this study is to assess the efficacy and clinical application of pedicled thoracoacromial artery perforator flaps for tracheal reconstruction.

Methods

Eight patients who underwent tracheal reconstructions with pedicled TAAP flaps between December 2017 and October 2019 were retrospectively reviewed.

Results

All of the pedicled TAAP flaps in our study survived. The flap size ranged from 2 cm × 5 cm to 4 cm × 10 cm, and the size of each island of one double-island flap was 2 cm × 2.5 cm. The mean thickness was 0.6 cm, and the pedicle length varied between 6 and 9 cm (mean 7.9 cm). The mean time of flap harvest was 17 min. The mean age of the patients was 62.4 years and five elderly patients had comorbidities, such as diabetes, hypertension and asthma. One patient received a double-island flap for tracheal and esophageal reconstruction, and the other patient received simple tracheal reconstruction. One patient died due to cancer metastasis. Six patients obtained functional recovery of breathing, except one patients who did not experience closure of the tracheostomy opening due to uncompleted I131 treatment.

Conclusion

Pedicled TAAP flaps provide a short harvesting time, thin thickness and stable blood supply, and they do not require microsurgical skills. This flap is a good choice for the reconstruction of tracheal defects, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

From the clavicle to the windpipe: Tracheal window resections reconstructed with calcifying periosteum in thyroid cancer

OBJECTIVES

We aimed to evaluate the outcomes of tracheal window resection and reconstruction using a vascularized periosteal flap (intended for calcification) harvested from the medial clavicle. This is one of several surgical techniques for tracheal resection and reconstruction used for patients with thyroid carcinoma invading the trachea. Importantly, in partial tracheal resection postoperative dynamic airway collapse must be prevented. Reconstruction of the tracheal defect with a vascularized periosteal flap is one method of achieving a stable airway.

METHODS

Twelve patients with locally advanced thyroid carcinoma who underwent tracheal resection and reconstruction at Oslo University Hospital from 2004 to 2017 were studied retrospectively. The primary outcome was a stable airway not requiring airway stenting. The secondary outcomes were the time to decannulation, morbidity, and survival.

RESULTS

Eleven of 12 patients did not require airway stenting postoperatively after a median of 111 days. Seven patients developed postoperative complications. The median observation time was 74.8 months (range 10.5-153.5) for all patients. The median disease-free survival was 40 months (range 0-147). By February 1, 2020, seven patients were alive, of whom five showed no evidence of disease.

CONCLUSIONS

Tracheal reconstruction with a vascularized periosteal flap yielded good results in terms of establishing a stable airway. This procedure is a viable reconstructive option that allows for decannulation by preventing airway collapse, thereby potentially mitigating the need for end-to-end (ETE) anastomosis or sleeve resections. For selected patients, this procedure may prevent local fatal complications from thyroid cancer invading the trachea.

LEVEL OF EVIDENCE

Level 4.

The prefabricated supraclavicular artery flap in high-risk tracheal stenosis patients

OBJECTIVES/HYPOTHESIS

Primary tracheal resection in appropriately selected patients with tracheal stenosis achieves >90% success rate. Risk factors for complications have been identified, making some patients high risk for this procedure. Herein is a review and discussion of a novel treatment method for tracheal stenosis utilizing a prefabricated composite auricular cartilage graft embedded in a supraclavicular artery island flap (pSCAIF) for tracheal reconstruction in high-risk patients.

STUDY DESIGN

Retrospective case series.

METHODS

After institutional review board approval, cases were analyzed after data collection. Between 2014 and 2016, eight patients underwent airway reconstruction using an auricular cartilage graft prefabricated within a supraclavicular artery island flap reconstruction; all of these were included in the study. Each case was reviewed, and relevant details of patient and disease characteristics, operative course, postoperative course, decannulation, and status at last follow-up were isolated and reported.

RESULTS

Seven of eight patients were female. The most common cause of stenosis was iatrogenically induced multilevel stenosis (7/8 patients). All patients had undergone prior airway procedures, were high risk based on comorbid conditions, and underwent grafting and reconstruction with a composite supraclavicular island flap. All patients continue to follow up in a multidisciplinary clinic, and at last follow-up, eight of eight patients were successfully decannulated.

CONCLUSIONS

The pSCAIF is a novel method for tracheal reconstruction. The analysis of the prefabricated locoregional approach cohort supports its utility for tracheal reconstruction in patients with complicated multilevel stenosis and adverse comorbidities and characteristics.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:641-648, 2020.

Long-Segment Tracheal Reconstruction With Free Radial Forearm Flap Reinforced by Rib Cartilage

Long-segment tracheal reconstruction remains a challenge. The ideal tracheal substitute should be an epithelialized tube to prevent stenosis and sufficiently rigid to maintain airflow patency. An autologous technique using a radial forearm free flap reinforced by rib cartilage has been recently described for tracheal reconstruction. We report here two cases of complex tracheal reconstruction with a modification of this technique, which consists of the creation of two independent skin paddles to allow the reconstruction of the trachea and a second adjacent defect (eg, cervical skin, esophagus). Airway patency was achieved with no stenosis, prolonged stenting, fistula, or necrosis after 26 and 44 months, respectively. We suggest that the satisfactory outcome obtained with this modified technique is a valuable option for tracheal and adjacent defect reconstruction without the need for a second flap.

Free posterior tibial artery perforator flap for 2-stage tracheal reconstruction in patients after resection of well-differentiated thyroid carcinoma invading the trachea

Background

The present study was conducted to explore the efficacy of using a free posterior tibial artery perforator flap (FPTAPF) for trachea reconstruction after resection of well‐differentiated thyroid carcinoma (WDTC) invading the trachea.

Methods

We retrospectively collected and analyzed clinical and surgical data from 14 patients who underwent tracheal reconstruction using a FPTAPF after resection of WDTC invading the trachea between August 2014 and July 2017.

Results

Satisfactory tracheal structure and functional recovery were obtained in 11 of the 14 patients. One patient had breathing difficulties after tracheostomy closure tests because of bilateral recurrent laryngeal nerve damage caused by disease invasion. Tracheostomy incision was not closed in 2 patients because they received postoperative adjuvant radioactive iodine 131 treatment.

Conclusion

Satisfactory tracheal reconstruction results were achieved in patients with resection of WDTC invading the trachea, indicating that a FPTAPF is a safe and reliable choice for management.

Immediate tracheal reconstruction with forearm flap and bone graft

BACKGROUND

"Window" resection of the trachea is sometimes performed to remove tumors invading the trachea. Here, we present a novel reconstructive procedure to this end.

METHODS

Eleven patients (mean age, 64 years; range, 46-80 years) were included. Primary diagnoses included thyroid cancer and adenoid cystic carcinoma of the trachea. All defects were partial and located in the neck (mean width and length, 3/5 circle and 7.5 rings; range, 1/2-2/3 circle and 5-9 rings). Immediate 2-stage reconstruction was performed using a forearm flap and free bone graft. The bone graft was utilized as a supportive skeleton. A tracheostoma was left open for several months following the initial surgery, and then closed.

RESULTS

The mean flap size was 6.1 × 9.7 cm (range, 6-7 × 7-16 cm). Mean number of grafted bone strips and length were 1.6 (range, 1-3) and 6.1 cm (range, 4.5-7 cm). All flaps survived. Five patients developed complications in the neck, including surgical site infections (SSIs), recurrent nerve palsy, and lymphorrhea. Four patients developed donor site complications, including clavicular fracture and SSIs. Mean postoperative follow-up lasted 85 months (range, 11-149 months). Normal speech was restored in 9 patients. Stoma closure was abandoned in 2 patients, because 1 patient showed vocal cord fixation with advanced age and the other showed bone graft loss following SSI.

CONCLUSIONS

Creating a tracheostoma during the first operation prevents postoperative airway compromise. Our bone graft placement easily achieves tracheal rigidity. This procedure is simple and safe for tracheal window defect repair.

Porous Three-Dimensional Silk Fibroin Scaffolds for Tracheal Epithelial Regeneration in Vitro and in Vivo

The regeneration of functional epithelial lining is critical for artificial grafts to repair tracheal defects. Although silk fibroin (SF) scaffolds have been widely studied for biomedical application (e.g., artificial skin), its potential for tracheal substitute and epithelial regeneration is still unknown. In this study, we fabricated porous three-dimensional (3D) silk fibroin scaffolds and cocultured them with primary human tracheobronchial epithelial cells (HBECs) for 21 days in vitro. Examined by scanning electronic microscopy (SEM) and calcein-AM staining with inverted phase contrast microscopy, the SF scaffolds showed excellent properties of promoting cell growth and proliferation for at least 21 days with good viability. In vivo, the porous 3D SF scaffolds (n = 18) were applied to repair a rabbit anterior tracheal defect. In the control group (n = 18), rabbit autologous pedicled trachea wall without epithelium, an ideal tracheal substitute, was implanted in situ. Observing by endoscopy and computed tomography (CT) scan, the repaired airway segment showed no wall collapse, granuloma formation, or stenosis during an 8-week interval in both groups. SEM and histological examination confirmed the airway epithelial growth on the surface of porous SF scaffolds. Both the epithelium repair speed and the epithelial cell differentiation degree in the SF scaffold group were comparable to those in the control group. Neither severe inflammation nor excessive fibrosis occurred in both groups. In summary, the porous 3D SF scaffold is a promising biomaterial for tracheal repair by successfully supporting tracheal wall contour and promoting tracheal epithelial regeneration.

Tracheocutaneous Fistula Closure with Turnover Flap and Polydioxanone Plate

An alternative surgical treatment is proposed for closure of tracheocutaneous fistulas. The authors present a new technique for reconstruction of persistent tracheocutaneous fistula resultant from temporary tracheostomy. The single-stage closure under local anesthesia involves a fistulous tract turnover flap with a perforated 0.15 mm polydioxanone plate between the flap and the subcutaneous closure. This article presents 3 cases of persistent tracheocutaneous fistula treated by this method. At follow-up examination after follow-up, no recurrent fistula formation had occurred, and no respiratory deformity was present.

Primary reconstructive method for tracheal defect from invasion by differentiated thyroid carcinoma

Differentiated thyroid carcinoma is not highly malignant, and thus surgical resection is the most common treatment even if the carcinoma has invaded the trachea. Although some cases exist in which the carcinoma invades the trachea, using the tracheal window resection method allows complete resection of the carcinoma. Yet these patients must often control a large tracheocutaneous wound until reconstructive surgery is performed because such surgery occurs secondarily. Our hospital admitted three patients for which tracheally invasive, differentiated thyroid carcinoma was surgically resected. Tracheal defects of 1/2 to 2/3 of the tracheal circumference were reconstructed primarily using the free forearm flap and costal cartilage during carcinoma resection. Following surgery, only a small tracheocutaneous fistula remained open, which was closed at about three months post-operation. The reconstructed tracheal space and transferred costal cartilage thickness were monitored by CT scan imaging at about 12 months post-operation. Details of the reconstructive method and postoperative changes in the reconstructed trachea and thickness of the costal cartilage are described in this report.

Prosthetic reconstruction of the trachea: A historical perspective

This review discusses the history of tracheal reconstruction; from early work to future challenges. The focus is primarily on prosthetic tracheal reconstruction in the form of intraluminal stents, patch repairs, circumferential repairs and replacement of the trachea. A historical perspective of materials used such as foreign materials, autografts, allografts, xenografts and techniques, along with their advantages and disadvantages, is provided.

Repair of large airway defects with bioprosthetic materials

OBJECTIVE

Patients with complicated airway defects that exceed the limits of primary repair represent a challenging clinical problem and require alternative techniques for repair. The aim of this study was to evaluate bioprosthetic reconstruction of large tracheal and bronchial defects.

METHODS

Retrospective chart review of patients treated at a single tertiary center from 2008 to 2015 who underwent repair of tracheal or bronchial defects with a bioprosthetic device, namely aortic homograft or acellular dermal matrix.

RESULTS

Eight patients, 3 men and 5 women with a mean age of 54 ± 13 years, underwent closure of complex central airway defects with bioprosthetic material. All but 1 patient underwent prior operative or stenting procedures. Three patients had isolated airway defects, whereas 5 had fistulas between the airway and enteric tract. Defects involved the membranous wall of the trachea (n = 5), the anterior wall of the trachea (n = 1), or the main stem bronchus (n = 2). Five reconstructions were with aortic homograft and 3 with acellular dermal matrix. Bioprosthetic material was buttressed with muscle flap (n = 4), omentum (n = 2), or left unbuttressed (n = 2). The airway defect was successfully closed in all patients. There was no postoperative mortality or recurrence of the airway defect in short-term follow-up. Two patients required debridement of granulation tissue and 1 additional patient required airway balloon dilation. Progression of underlying metastatic disease explained the majority of long-term mortality (75%).

CONCLUSIONS

Bioprosthetic materials represent a viable option for management of large airway defects, including airway-enteric fistulae, that exceed the limits of primary repair.

Microsurgical reconstruction of combined tracheal and total esophageal defects

OBJECTIVE

Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction.

METHODS

A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap.

RESULTS

Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet.

CONCLUSIONS

Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival.

Pediatric airway reconstruction with a prefabricated auricular cartilage and radial forearm free flap

Prefabricated composite free flaps for complex airway reconstruction have been described for an adult series at our institution. We extended this approach to a pediatric patient with lifelong subglottic stenosis who had failed previous open airway reconstructions. A staged procedure was utilized in which a composite graft was created using conchal cartilages and a radial forearm free flap. This reconstruction improved the patency of her airway and decreased her dependency on intermittent airway dilations. Airway reconstruction with prefabricated conchal cartilage composite free flaps may be used as a salvage procedure for complex pediatric airway reconstruction when other methods have failed.

Advances in tracheal reconstruction

SUMMARY

A recent revival of global interest for reconstruction of long-segment tracheal defects, which represents one of the most interesting and complex problems in head and neck and thoracic reconstructive surgery, has been witnessed. The trachea functions as a conduit for air, and its subunits including the epithelial layer, hyaline cartilage, and segmental blood supply make it particularly challenging to reconstruct. A myriad of attempts at replacing the trachea have been described. These along with the anatomy, indications, and approaches including microsurgical tracheal reconstruction will be reviewed. Novel techniques such as tissue-engineering approaches will also be discussed. Multiple attempts at replacing the trachea with synthetic scaffolds have been met with failure. The main lesson learned from such failures is that the trachea must not be treated as a "simple tube." Understanding the anatomy, developmental biology, physiology, and diseases affecting the trachea are required for solving this problem.

Advances in tracheal reconstruction

Summary:

A recent revival of global interest for reconstruction of long-segment tracheal defects, which represents one of the most interesting and complex problems in head and neck and thoracic reconstructive surgery, has been witnessed. The trachea functions as a conduit for air, and its subunits including the epithelial layer, hyaline cartilage, and segmental blood supply make it particularly challenging to reconstruct. A myriad of attempts at replacing the trachea have been described. These along with the anatomy, indications, and approaches including microsurgical tracheal reconstruction will be reviewed. Novel techniques such as tissue-engineering approaches will also be discussed. Multiple attempts at replacing the trachea with synthetic scaffolds have been met with failure. The main lesson learned from such failures is that the trachea must not be treated as a “simple tube.” Understanding the anatomy, developmental biology, physiology, and diseases affecting the trachea are required for solving this problem.

Tissue engineering for plastic surgeons: a primer

A central tenet of reconstructive surgery is the principle of "replacing like with like." However, due to limitations in the availability of autologous tissue or because of the complications that may ensue from harvesting it, autologous reconstruction may be impractical to perform or too costly in terms of patient donor-site morbidity. The field of tissue engineering has long held promise to alleviate these shortcomings. Scaffolds are the structural building blocks of tissue-engineered constructs, akin to the extracellular matrix within native tissues. Commonly used scaffolds include allogenic or xenogenic decellularized tissue, synthetic or naturally derived hydrogels, and synthetic biodegradable nonhydrogel polymeric scaffolds. Embryonic, induced pluripotent, and mesenchymal stem cells also hold immense potential for regenerative purposes. Chemical signals including growth factors and cytokines may be harnessed to augment wound healing and tissue regeneration. Tissue engineering is already clinically prevalent in the fields of breast augmentation and reconstruction, skin substitutes, wound healing, auricular reconstruction, and bone, cartilage, and nerve grafting. Future directions for tissue engineering in plastic surgery include the development of prevascularized constructs and rationally designed scaffolds, the use of stem cells to regenerate organs and tissues, and gene therapy.

One-stage reconstruction of a tracheal defect with a free radial forearm flap and free costal cartilage grafts

Reconstructing the trachea is challenging because of its multilayer structure and airway function; multiple procedures are often required. We report a case of one-stage reconstruction for a tracheal defect. The surgery was performed with a free radial forearm flap and free costal cartilage grafts. Air leakage occurred postoperatively but healed without additional surgery. The reconstructed trachea has retained its shape, diameter and airway function for 14 months despite the patient's history of radiotherapy. This one-stage procedure with well-vascularised tissue was successfully used to reconstruct a stable, well-functioning trachea.

Complex adult laryngotracheal reconstruction with a prefabricated flap: a case series

BACKGROUND

Laryngotracheal stenosis (LTS) can cause persistent or recurrent airway obstruction. Although there is extensive literature on surgical techniques to treat LTS at onset, there are few techniques described for complex adult LTS after failed prior airway surgery. We describe a procedure used successfully in 3 patients who required structural augmentation for complex LTS.

METHODS

Patients were treated with staged reconstruction using a prefabricated composite graft consisting of auricular cartilage and a radial forearm free flap.

RESULTS

All patients underwent successful reconstruction with good wound healing and are tolerating oral diets. Two patients have been successfully decannulated.

CONCLUSION

A delayed prefabricated graft using auricular cartilage in a radial forearm free flap is a viable surgical intervention in patients with complex adult LTS who are not candidates for conventional approaches.

Current concepts in tracheal reconstruction

PURPOSE OF REVIEW

Many patients require tracheal reconstruction either for tracheal stenosis/malacia or following tumor extirpation. However, such patients can be debilitated following failed conventional treatments. Recent advances in tissue engineering and vascularized composite grafts are accelerating the field of tracheal reconstruction. This article reviews new clinical concepts for tracheal reconstruction.

RECENT FINDINGS

Novel treatments include composite autografts, allografts, chimeric autografts and allografts, tissue-engineered grafts, prosthetic scaffolds, and the use of free-tissue vascularized carriers.

SUMMARY

New procedures for tracheal reconstruction hold much promise for treating difficult tracheal disorders and improving the quality of life for affected patients. Many of the techniques reviewed herein are single case series and require further investigation and validation.