Buried anterolateral thigh flap for pharyngoesophageal reconstruction: Our method for monitoring

Edge De-epithelialization for Reducing Pharyngocutaneous Fistula in Patch Free Flap Reconstructions for Salvage Total Laryngectomy Defects: A Case-Control Study

BACKGROUND

The leakage of saliva through the deep neck region from a pharyngocutaneous fistula could cause devastating complications, including vascular ruptures leading to mortality. While a partial pharyngoesophageal defect is created after total laryngectomy, a patch pattern of hypopharyngeal reconstruction is required, for which a fasciocutaneous free flap is usually applied. If radiotherapy fails to cure pharyngeal cancer, salvage total laryngectomy (STL) is needed. However, postradiation tissues tend not to heal well, and the incidence of pharyngocutaneous fistula therefore increases. We proposed an edge-epithelialization method to address this problem and conducted a retrospective study for comparison.

METHODS

The inclusion criteria were patients with head and neck cancer who underwent total laryngectomy that immediately required patch free flap reconstruction at a single medical center (January 2012-December 2021). Receipt of presurgical radiotherapy, hospitalization duration, and the presence of postoperative complications were recorded.

RESULTS

The included patients were separated into two groups: Group A (edge de-epithelialization not adopted) (n = 79) and Group B (edge de-epithelialization adopted) (n = 51). Forty-four and twenty-two patients in Groups A and Group B, respectively, received preoperative radiotherapies and simultaneous STL and fasciocutaneous free flap reconstructions. The incidence of pharyngocutaneous fistula was significantly lower in Group B (p = 0.0145). This phenomenon was the same for patients who underwent preoperative radiotherapy only (p = 0.0470) but not for patients who did not receive preoperative radiotherapy (p = 0.2363).

CONCLUSIONS

Edge de-epithelialization is an effective method for reducing pharyngocutaneous fistula formation in patch free flap reconstructions after STLs.

Pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction

BACKGROUND

Total laryngeal and hypopharyngeal resection remained to be the mainly treatment option for advanced hypopharyngeal cancer, which resulted in complicated reconstructive challenge for circumferential hypopharyngeal defect. The pedicled thoracoacromial artery compound flaps included Thoracoacromial artery perforator (TAAP) flap and pectoralis major myocutaneous (PMMC) flap. This study is to evaluate the clinical application of the pedicled thoracoacromial artery compound flaps for circumferential hypopharyngeal reconstruction.

METHODS

From May 2021 to April 2022, four hypopharyngeal cancer patients with circumferential hypopharyngeal defects were reconstructed by the pedicled thoracoacromial artery compound flaps. All patients were males. Patient age ranged from 35 to 62 years (average, 50 years). The Shoulder function were evaluated by SPADI. The average follow-up was 10.25 months (range from 4 to 18 months).

RESULTS

All of the pedicled thoracoacromial artery compound flaps in our study survived. The defect length between tongue base and cervical esophagus ranged from 8 to 10 cm after total laryngeal and hypopharyngeal resection. The TAAP flap size ranged from 6 × 7 cm to 7 × 10 cm, and the PMMC flap size ranged from 6 × 7 cm to 9 × 12 cm. The pedicle length of TAAP and PMMC flaps varied, respectively, from 5 to 8 cm (mean 6.5 cm) and 7 cm to 11 cm (mean 8.75 cm). The mean time of TAAP and PMMC flaps harvest was, respectively, 82 min and 39 min. All patients were able to resume soft diet in the fourth week of postoperation, but one patient was operated by gastrostomy in the second month of postoperation because of pharyngeal cavity stenosis, and the patient successfully resumed oral soft diet by endoscopic balloon dilation after postoperation radiotherapy. All patients have resumed oral feeding at last. There were mild dysfunction for our patients according to SPADI during the mid-long follow-up.

CONCLUSIONS

The pedicled thoracoacromial artery compound flaps have stable blood supply and provide adequate muscle coverage for greater protection during radiotherapy, and the microsurgical skills have no requirement. Therefore, the compound flaps provide a good choice for the reconstruction of circumferential hypopharyngeal defect, especially in the aged or patients with comorbidities who are not able to tolerate prolonged surgery.

modified tubed anterolateral free flap for reconstruction of total laryngopharyngectomy

Background: A tubed anterolateral thigh (ALT) flap has become a reliable option for laryngopharyngeal defects; however, successful reconstruction remains challenging. Prevention of fistulae, resurfacing of the neck and flap monitoring are key issues that surgeons have sought to address through various flap modifications. Here we describe a chimeric design of the tubed ALT flap which tackles these and other challenges. Methods: Fourteen cases requiring ALT flaps were harvested for reconstruction of total laryngopharyngectomy defects between 2017 and 2019. Each flap was raised on at least two perforators of the descending branch of the lateral circumflex femoral artery (dbLCFA) or both the dbLCFA and transverse branch of the lateral circumflex femoral artery (tbLCFA) to create a chimeric flap. The primary cutaneous paddle was tubed to reconstruct the oesophagus, and the secondary component was inset to the neck as a skin-monitoring paddle. A strip of vascularised vastus lateralis was harvested in the primary paddle continuing with the flap and sutured along the neopharynx suture line, an additional layer preventing anastomotic leak. Results: Patients averaged 61.1 years of age. An average of 2.4 perforators were included per flap. All flaps survived. Donor sites were closed primarily in all cases. Barium swallow was performed in 71.4 per cent of cases (10/14). Fistula occurred in 7.1 per cent of patients (1/14). Patients were followed up for an average of 13 months. Conclusion: Our chimeric ALT free flap design provides a reliable pharyngeal reconstruction, and allows for flap monitoring and neck resurfacing when required, with a low rate of clinically significant leaks or fistula.

Comparison between anterolateral thigh free flap and jejunal flap for tissue reconstruction in patients underwent resection of pharyngoesophageal squamous cell carcinoma after radiotherapy failure: a retrospective study

BACKGROUND

Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with worsening tissue adhesion and necrosis after radiotherapy failure. However, the results of tissue reconstruction and postoperative complications of these two flaps are controversial. The purpose of this study was to compare outcomes between group ALT free flap and group JF in PESCC after radiotherapy failure.

METHODS

Intraoperative information and postoperative outcomes of patients with PESCC after radiotherapy failure who underwent ALT and JF reconstruction from January 2005 to December 2019 were compared and analyzed.

RESULTS

The defect size of ALT (Numbers, 34) and JF (Numbers, 31) was 36.19 ± 11.35 cm² and 35.58 ± 14.32 cm² (p = 0.884), respectively. ALT and JF showed no significant difference in operation time (p = 0.683) and blood loss (p = 0.198). For postoperative outcomes within 30 days both in recipient site and donor site including wound bleeding, wound dehiscence, wound infection, and pharyngocutaneous fistula, ALT free flap and JF showed similar results. Flap compromise (Numbers, 2 VS.3, p = 0.663), flap take backs (Numbers, 1 VS.1, p = 1.000), partial flap failures (Numbers, 4 VS.2, p = 0.674), and total flap failures (Numbers, 0 VS.0, p = 1.000) showed no difference between the two groups. In addition, no significance was found in hypoproteinemia between the two groups (Numbers, 4 VS.2, p = 0.674). ALT free flap was not statistically different from JF in the incidence of dysphagia at the postoperative 6 months (Numbers of liquid diet, 5VS.5; Numbers of partial tube feeding, 6VS.7; Numbers of total tube feeding, 3VS.1, p = 0.790) and 12 months (Numbers of liquid diet, 8VS.7; Numbers of partial tube feeding, 8VS.7; Numbers of total tube feeding, 5VS.5, p = 0.998). The cause of dysphagia not found to differ between the two groups both in postoperative 6 months (p = 0.814) and 12 months (p = 0.845).

CONCLUSION

Compared with JF, ALT free flap for PESCC patients after radiotherapy failure showed similar results in postoperative outcomes. ALT free flap may serve as a safe and feasible alternative for PESCC patients after radiotherapy failure.

Training the Trainers in Microsurgery: A Success Story from Vietnam's Hanoi National Hospital of Odonto-stomatology

Background:

Microsurgery is a highly specialized skill that requires advanced training. This is a recount of the 12-year development of Hanoi National Hospital of Odonto-Stomatology (NHOS) from a basic plastic surgery unit to a high-volume, subspecialized reconstructive center.

Methods:

We present a 12-year retrospective account of the development of NHOS with a brief summary of microsurgical reconstructive outcomes.

Results:

From 2008 to 2020, NHOS has performed 665 microsurgical flaps for reconstruction of various maxillomandibular defects. In the pioneering stage (2008-2011), without surgical microscopes, all five free flaps failed. After acquiring a microscope and mentoring from Hanoi's 108 Military Hospital, mandibular bone defect reconstruction with free fibula flaps had 85% success rate. In the growth stage (2012-2015), reconstruction advanced toward more complex defects requiring soft tissue, with a 98.7% success rate. The maturation stage (2016-2020) focused on refinement of reconstructive service to provide subspecialized care for malignant head and neck cancer patients with help from Taiwan's E-Da Hospital and Operation Smile's charity program. The charity mission trips were structured to facilitate good quality teaching rather than hit a quantitative goal of the number of surgeries done. And with a success rate of 99.4%, we have begun further education of the plastic surgery community in Vietnam.

Conclusions:

Our rapid 12-year maturation into a high-volume, subspecialized microsurgical center is the embodiment of the generous efforts of many international friends who invested their time and expertise. And we highly recommend charity mission trips to adopt the “training the trainers” concept to maximize lasting, local impact.

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part II: Clinical application

Despite the high success rate of micro-vascular flaps, anastomosis compromise occurs in 5-10% and that can lead to flap failure. Reliable monitoring of the flap is therefore of similar importance to that of the precise surgical procedure itself. Multiple methods have been reported for monitoring of the flap vitality, the first one being direct visual monitoring. In buried flaps direct visualisation is not feasible or is unreliable. In these cases we can extend the buried flap to expose a segment of it to act as a monitoring sentinel. For the purpose of this review we used our clinical experience as a starting point, and for the extended information and expertise we conducted a search of the PubMed database. Over 40 monitoring techniques have been reported to-date. Direct visual monitoring is still generally used method with a reliability of up to 100% and an overall success rate of up to 99%. Direct visualisation remains as the simplest, cheapest and yet a very reliable method of flap monitoring. In this review we provide a description of various possible techniques for externalising part of a buried flap, define the tissues that can be used for this purpose and we summarise the procedures that should be followed to achieve the best reliability and validity of monitoring the skin island.

Modern postoperative monitoring of free flaps

PURPOSE OF REVIEW

Flap failure in microvascular reconstruction is a costly complication with total flap loss being the worst-case scenario. With the aim to rapidly identify a postoperative circulatory problem, some susceptible flaps can be saved by careful clinical monitoring or by various technical monitoring methods. In head and neck surgery, where the flaps are often buried and difficult to monitor clinically, a reliable technical monitoring method would be useful. A broad range of different techniques are in use varying according to practical and personal preferences among clinics and surgeons. However, no evidence for any particular technique being superb has emerged. We review reports of some frequently used and modern free flap monitoring techniques.

RECENT FINDINGS

Clinical monitoring is still the gold standard to which other techniques are compared to. Laser Doppler flowmetry and near-infrared spectroscopy have been reported to identify early circulatory problems, but both techniques are not well suited for buried flaps. Implantable Doppler, flow coupler, partial tissue oxygen pressure and microdialysis are invasive monitoring methods suitable for buried flaps.

SUMMARY

More research with practical and clinically relevant parameters, that is flap salvage rate, false positive rate and cost-efficiency are needed before objective comparisons between different monitoring techniques can be made.

The free inverted omega-shaped flap for circumferential hypopharyngeal reconstruction with simultaneous neck skin defect

BACKGROUND

Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem.

METHODS

From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy.

RESULTS

The average flap size was 29 × 8 cm (range: 25-31 × 6-10 cm² ). An average of 2.6 perforators was included in each flap (2-4 perforators/flap). All flaps survived. One venous thrombosis was noted and salvaged after thrombolectomy and vein graft. The mean follow-up period was 25 months. The fistula rate was 21.4% (three patients). One fistula never healed because of early recurrence; one fistula healed after surgical intervention; and one fistula need a loco-regional flap for secondary reconstruction. Three postoperative strictures were noted (21.4%).

CONCLUSION

For the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:51-59, 2018.

Postoperative care and monitoring of the reconstructed head and neck patient

Reconstruction of head and neck patients using free tissue transfer is perhaps the most challenging of areas in the human body. Although complications are inevitable in a percentage of patients, it is good postoperative care and monitoring that determines the success or failure of the reconstruction and also permits early salvage of a failing free flap. Teamwork and cooperation among members of the reconstructive team are critical. Here we review the significance of clinical care and monitoring of reconstructed head and neck patients in the intraoperative and postoperative periods. We also review different techniques and strategies for flap monitoring and anticoagulation used for free tissue transfers.