Oropharyngeal reconstruction after transoral robotic surgery

PURPOSE OF REVIEW

Transoral robotic surgery (TORS) has experienced an evolution in recent years. This technique has proved to be a safe and effective method for extirpation of select oropharyngeal tumors. Advances in technology as well as improved surgeon experience allow for the resection of larger, more complex cancers. Although healing by secondary intention remains the current standard for limited oropharyngeal defects, larger resections demand reconstruction with vascularized tissue to minimize morbidity and optimize functional outcomes. The objective of this review is to evaluate recent literature regarding oropharyngeal reconstruction after TORS.

RECENT FINDINGS

A variety of reconstructive options to manage oropharyngeal defects exist. Several reconstructive algorithms have been suggested; however, careful consideration must be used to select the most ideal flap type. Locoregional flaps have shown excellent functional outcomes with limited morbidity. An increase in free flap reconstruction has been demonstrated, particularly among patients with larger TORS defects and following chemoradiation therapy. Despite limited data, robotic-assisted flap inset and microvascular anastomosis has recently shown promise.

SUMMARY

Reconstruction and flap selection following TORS should be tailored to the patient and unique oropharyngeal defect. Functional outcomes are promising with low complication rates among these patients.

Reconstruction following transoral robotic surgery for head and neck cancer: Systematic review

We performed a systematic review to characterize reconstructive modalities and postoperative surgical outcomes following TORS resection. A search of the PubMed, SCOPUS, and EMBASE databases was conducted to identify studies describing patients undergoing reconstruction of TORS defects. Twenty-six studies met inclusion criteria, consisting of 260 patients who underwent TORS resection followed by reconstruction. Twenty-one studies reported tumor classification information, with TORS performed for 44 (23.0%) T1, 86 (45.0%) T2, 33 (17.3%) T3, and 28 (14.7%) T4 tumors. Eighteen distinct reconstructive modalities were described in the studies identified, including nine unique free flap types. The most commonly performed reconstruction was the radial forearm free flap (RFFF), accounting for 121/260 (46.5%) of reconstructions performed. Reported surgical complications included 5 pharyngocutaneous fistulae, 13 hemorrhagic complications, 24 infectious complications, and 5 free flap failures. Our findings demonstrate favorable surgical outcomes but minimal quantitative functional data to compare reconstructive options following TORS.

The Nasoseptal Flap for Reconstruction of Lateral Oropharyngectomy Defects: A Clinical Series

OBJECTIVES/HYPOTHESIS

To study use of the nasoseptal flap (NSF) to reconstruct lateral transoral robotic surgery (TORS) oropharyngectomy defects.

STUDY DESIGN

Retrospective case series.

METHODS

A clinical series of six patients undergoing NSF reconstruction of lateral TORS oropharyngectomy defects was retrospectively studied. All patients underwent TORS for the treatment of intermediate-risk human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma of the lateral pharyngeal wall between January and June 2017. All patients underwent NSF reconstruction of lateral TORS defects with retrospective analysis of outcomes and complications.

RESULTS

Six patients underwent NSF reconstruction of lateral TORS defects. Operative times decreased from 180 minutes to 90 minutes over the study period. There were two cases of partial flap dehiscence and partial necrosis. There were no major donor site complications. All patients had temporary nasal obstruction and crusting. Two experienced temporary aural fullness. In all patients, the lateral wall was mucosalized in 1-3 weeks. Cephalometric analysis of preoperative imaging revealed that patients with high-arched palates (>3 cm) and defect lengths that are longer than NSF flap lengths are poor candidates for this technique.

CONCLUSIONS

This NSF is a vascularized, locoregional rotational flap that can reconstruct lateral TORS defects in salvages cases or those where the parapharyngeal carotid or mandibular bone are exposed. Postoperative morbidity is limited to temporary nasal dyspnea, aural fullness, and crusting. Preoperative imaging can determine which patient will have successful defect coverage.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:53-60, 2022.

Reconstruction of TORS oropharyngectomy defects with the nasoseptal flap via transpalatal tunnel

The nasoseptal flap (NSF) has been described as reconstructive option for soft palate defects following transoral robotic surgery (TORS). As described, this technique is does not provide adequate coverage of the lateral oropharyngeal wall, parapharyngeal space, exposed vessels, or exposed mandibular bone. The NSF for TORS reconstruction has been limited to soft palate reconstruction, given the limitations on length when passed via the nasopharynx. In this article, we describe (1) a novel technique for TORS reconstruction using direct transposition of the ipsilateral NSF into the oropharynx via a transpalatal tunnel at the hard-soft palate junction, and (2) its use in select patients.

Longus Capitis Reconstruction of the Soft Palate

Soft palate (SP) reconstruction remains a challenge for the head and neck reconstructive surgeon. One favorable local flap option is the longus capitis muscle (LCM), a deep neck flexor with redundant muscle function, appropriate bulk, and a relatively straightforward surgical harvest. A retrospective review of 3 patients with T2 to T4 tonsil squamous cell carcinoma requiring SP resection and LCM reconstruction at a single institution was performed. Three patients underwent primary transoral resection, all resulting in at least 50% full-thickness SP defects. Reconstruction comprised a superiorly based LCM local flap. Patients underwent adjuvant (chemo)radiation therapy as indicated. Within 3 to 8 months, each patient was tolerating a full oral diet with no dysphagia, nasal regurgitation, or velopharyngeal insufficiency. For select patients with SP defects, a superiorly based LCM flap may provide a functionally acceptable reconstruction with minimal donor site morbidity.