Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature

Associations between hypopharyngeal defect closure and quality of life in long-term total laryngectomy survivors

BACKGROUND

Few studies have examined health-related quality of life (HRQOL) outcomes in long-term total laryngectomy survivors in relation to the type of hypopharyngeal defect.

METHODS

A cross-sectional study was performed in long-term total laryngectomy survivors, treated between 2000 and 2020. The primary outcome was HRQOL, assessed using the FACE-Q Head and Neck Cancer Module, in relation to the type of hypopharyngeal closure (primary closure, partial or circumferential reconstruction).

RESULTS

Seventy-nine survivors were included with a median follow-up of 92.1 months (IQR 75.6-140.2 months). Patients requiring partial hypopharyngeal reconstruction (n = 18) scored significantly worse than patients with primary closure (n = 51) on 4 of 13 FACE-Q domains: functional domains of eating (p = 0.03), speech (p = 0.05), and swallowing (p = 0.03), and the psychological domain of speaking-related distress (p = 0.02). No statistically significant differences were found between the circumferential hypopharyngeal defect reconstruction group (n = 10). Stricture occurrence was the only clinical factor associated with worse eating, speaking, swallowing, eating-related distress, and cancer worry in multivariable analyses.

CONCLUSION

Several functional and psychological domains were significantly worse following partial hypopharyngeal reconstruction than in patients who received primary closure. Efforts to reduce stricture rates to enhance reconstructive outcomes following total laryngectomy merit further research.

Early Predictors of Fistula Formation Following Head and Neck Reconstruction

BACKGROUND

 Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation.

METHODS

 We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula.

RESULTS

 In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value.

CONCLUSION

 CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

Fasciocutaneous and jejunal free flaps for circumferential hypopharyngeal defect reconstruction: A 22-year multicenter cohort study

BACKGROUND

It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects.

METHODS

All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications.

RESULTS

In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007).

CONCLUSIONS

The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.

Successful cervicothoracic esophageal stricture treatment with partial sternectomy and a pedicled TAAP flap: A case report

Postoperative benign esophageal anastomotic leakage and stenosis are common complications after esophagectomy. Treatment options for anastomosis stenosis include endoscopic mechanical dilation, dilation-combined steroid injection, incisional therapy, stent placement, and self-bougienage. However, long-segmental cervicothoracic esophageal stenosis and cutaneous fistula are always refractory to conservative treatments and are clinically challenging. When lesions extend well below the thoracic inlet, transthoracic esophagectomy and alimentary canal reconstruction seem to be the common choice but are susceptible to perioperative mortality and donor-site sequelae, especially for patients with poor health conditions. In this report, we present a novel surgical approach for cervicothoracic esophageal stenosis and fistula via partial sternectomy and reconstruction with a pedicled thoracoacromial artery perforator flap. No recurrence or complications occurred throughout 3 months of follow-up. This case study adds new perspectives to the treatment of anastomotic stenosis.

Perforator‐based chimeric anterolateral thigh flap U‐shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes

BACKGROUND

Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes.

METHODS

We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires.

RESULTS

Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2.

CONCLUSIONS

The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.

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.

Reconstruction of hypopharyngeal defects with anterolateral thigh free flap: A single-center retrospective analysis

INTRODUCTION

Reconstruction of expanded hypopharyngeal defects following laryngo-hypopharyngectomy for surgical treatment of primary is still a challenge for head and neck surgeons. Tradiotionally, jejunal or radial forearm flaps are the common reconstructive choice. Recently, the anterolateral thigh (ALT) free flap has served for pharyngoesophageal reconstruction. The goal of this work is to describe a retrospective analysis about a five-year single-center experience in the reconstruction of post-operative hypopharyngeal defects with ALT free flap.

METHODS

A single-center retrospective study was performed, including patients treated for patients who underwent tumor surgery involving hypopharynx with ALT free flap reconstruction from 2015 to 2020. Exclusion criteria were paediatric (0-18 years) patients, and the absence of follow-up.

RESULTS

The study included 23 adult patients. The mean size of the flap was 90 cm² (range 60-130 cm²). The mean time required to harvest the antero-lateral tight flap was 70 min (range 35-120 min). The median age was 46.3 years (SD 15.81, range: 19-84 years), with a gender female prevalence (F = 48, M = 33). Mean follow-up was 77.7 months (min 4-max 361, SD 72.46). One patient (4.4 %) showed a hypopharyngeal stenosis.

CONCLUSION

ALT free flap represents a successful and versatile reconstructive option for hypopharyngeal defects extended to oropharynx and/or larynx following total laryngectomy with circumferential or partial hypopharyngectomy, regardless of the functional and aesthetic results, with minimal donor-site complication.

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.

Clinical outcomes following pharyngolaryngectomy reconstruction: a 20-year single-centre study

Background

Advanced malignant neoplasms of the larynx and hypopharynx pose many therapeutic challenges. Total pharyngolaryngectomy and total laryngectomy provide an opportunity to cure these tumours but are associated with significant morbidity. Reconstruction of the pharyngeal defect following total pharyngolaryngectomy demands careful consideration and remains an area of debate within surgical discussions.

Methods

This paper describes a systemic analysis of pharyngeal reconstruction following total pharyngolaryngectomy and total laryngectomy, leveraging data collected over a 20-year period at a large tertiary referral centre.

Results

Analysing 155 patients, the results show that circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. In addition, free tissue transfer in larger pharyngeal defects showed lower rates of post-operative anastomosis leak and stricture.

Conclusion

Pharyngeal resection carries a substantial risk of post-operative complications, and free tissue transfer appears to be an effective means of reconstruction for circumferential defects.

The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes

BACKGROUND

There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects.

METHODS

A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates.

RESULTS

Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013).

CONCLUSIONS

The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.

A New Classification System to Predict Functional Outcome after Laryngectomy and Laryngopharyngectomy

Simple Summary

Evaluation of the long-term functional outcome after primary or salvage laryngopharyngectomy. Long term functional outcome mainly depends on extent of pharyngectomy and salvage situation, which is reflected by our new classification system.

Abstract

(1) Objective: To evaluate long-term functional outcome in patients who underwent primary or salvage total laryngectomy (TL), TL with partial (TLPP), or total pharyngectomy (TLTP), and to establish a new scoring system to predict complication rate and long-term functional outcome; (2) Material and Methods: Between 1993 and 2019, 258 patients underwent TL (n = 85), TLPP (n = 101), or TLTP (n = 72). Based on the extent of tumor resection, all patients were stratified to (i) localization I: TL; II: TLPP; III: TLTP and (ii) surgical treatment (A: primary resection; B: salvage surgery). Type and rate of complication and functional outcome, including oral nutrition, G-tube dependence, pharyngeal stenosis, and voice rehabilitation were evaluated in 163 patients with a follow-up ≥ 12 months and absence of recurrent disease; (3) Results: We found 61 IA, 24 IB, 63 IIA, 38 IIB, 37 IIIA, and 35 IIIA patients. Complications and subsequently revision surgeries occurred most frequently in IIIB cases but rarely in IA patients (57.1% vs. 18%; p = 0.001 and 51.4% vs. 14.8%; p = 0.002), respectively. Pharyngocutaneous fistula (PCF) was the most common complication (33%), although it did not significantly differ among cohorts (p = 0.345). Pharyngeal stenosis was found in 27% of cases, with the highest incidence in IIIA (45.5%) and IIIB (72.7%) patients (p < 0.001). Most (91.1%) IA patients achieved complete oral nutrition compared to only 41.7% in class IIIB patients (p < 0.001). Absence of PCF (odds ratio (OR) 3.29; p = 0.003), presence of complications (OR 3.47; p = 0.004), and no need for pharyngeal reconstruction (OR 4.44; p = 0.042) represented independent favorable factors for oral nutrition. Verbal communication was achieved in 69.3% of patients and was accomplished by the insertion of voice prosthesis in 37.4%. Acquisition of esophageal speech was reached in 31.9% of cases. Based on these data, we stratified patients regarding the extent of surgery and previous treatment into subgroups reflecting risk profiles and expectable functional outcome; (4) Conclusions: The extent of resection accompanied by the need for reconstruction and salvage surgery both carry a higher risk of complications and subsequently worse functional outcome. Both factors are reflected in our classification system that can be helpful to better predict patients’ functional outcome.

Postoperative outcomes of free myocutaneous flap and pedicled myocutaneous flap for reconstruction in locally invasive thyroid carcinoma

Locally invasive thyroid carcinoma (TC) often involves trachea. In such patients, the trachea needs to be reconstructed after surgery. We discuss the postoperative outcome and complications after trachea reconstruction by free myocutaneous flap (FMF) and pedicled myocutaneous flap (PMF).From January 2009 to September 2019, the clinical data of 38 patients with TC were retrospectively analyzed. Demographics, pathologic results, neoplasm staging, surgical protocol, decannulation, subjective speech function, and complications were documented.A total of 38 patients were analyzed (22 FMFs and 16 PMFs). Of the 38 patients, there is a similar rate of decannulation (81.8% in FMF and 75% in PMF), subjective speech function and complications.The FMF reconstruction and the PMF reconstruction have a similar result in terms of postoperative outcome and complications.

Tubed Anterolateral Thigh Free Flap for Pharyngoesophageal Reconstruction

Caustic ingestions can severely injure the upper and lower aerodigestive tract, resulting in detrimental mucosal changes both acutely and chronically. Injuries are most severe following alkaline ingestion. Esophagectomy is often recommended in patients with high-grade esophageal injuries to mitigate the risk of perforation. Esophageal reconstruction after these injuries is often delayed, and staged, allowing adequate tissue stabilization before further manipulation. Here, we report on a 25 year-old woman who presented with a high-grade caustic esophageal injury following the ingestion of an alkaline drain cleaner. She underwent an emergent thoracic esophagectomy, gastrectomy and a cervical salivary esophagostomy. Post-operatively, she developed supraglottic and hypopharyngeal strictures, but maintained a functional larynx. She subsequently underwent a staged, extrathoracic total esophageal reconstruction using an anterolateral thigh (ALT) myocutaneous free flap with laryngeal preservation. Although serial esophageal dilatations and trans-oral laser procedures for pharyngeal strictures were required, she was able to maintain the ability to swallow.

Synchronous reconstruction of esophageal defect and voice with J-flap after laryngopharyngectomy: Indications and outcomes

BACKGROUND

The primary reconstruction goal for patients with laryngopharyngectomy is the restoration of esophagus, whereas voice reconstruction is less readily reconstructed. J-flap is a novel surgical technique designed to reconstruct voice and esophagus synchronously, permitting functional rehabilitation of aerodigestive tract after laryngopharyngectomy.

OBJECTIVES

This study aims to present indications, surgical steps, and outcomes of an innovative technique for synchronous reconstruction of the esophagus and voice tube with a free thigh flap (J-flaps).

METHOD

Single-center study from 2011 to 2017 recruiting patients with hypopharyngeal cancer needing laryngopharyngectomy and J-flaps reconstruction. Patient details were analyzed, and surgical outcomes were examined.

RESULTS

20 patients were recruited with an average age of 61. Tumor staging was IIB or above. The average follow-up period was 15 months. 65% of these patients resumed a full diet. The row phonation rate was 75%. The average maximum phonation time was 8.9 s, and the average number of counting in a breath was 14.

CONCLUSIONS

Most patients achieved a conversational level of speech capacity with a humanoid voice. J-flap can be utilized safely, supporting the social re-integration of these patients with their new voice.

Primary pharyngolaryngectomy with jejunal free flap reconstruction: a single centre's evolving experience

BACKGROUND

Head and neck squamous cell carcinoma, and in particular hypopharyngeal squamous cell carcinoma, has long been associated with disfiguring treatment options, significant morbidity and limited long-term survival outcomes. Total pharyngolaryngectomy (TPL) with free flap reconstruction followed by post-operative radiation therapy or chemoradiotherapy is a widely accepted treatment of choice for advanced disease of the hypopharynx.

METHODS

Our unit undertook a 11-year review of all primary TPL patients aiming to provide an update on survival outcomes, morbidity, post-operative complications and evolving management strategies. We report one of the largest single-centre series to date with 89 patients undergoing primary TPL between 2003 and 2013, and compare these outcomes to 180 patients undergoing TPL at the same facility in the previous 23 years.

RESULTS

Between study periods, we saw a shift in patient population towards higher stage disease (T-stage 3 or 4 97% 2003-2013; 68% 1979-2002) and increased nodal involvement (node positive 88% 2003-2013; 70% 1979-2002) without a subsequent reduction in 5-year disease-specific survival (52% 2003-2013; 52% 1979-2002) or 5-year overall survival (32% 2003-2013; 33% 1979-2002).

Simultaneous Restoration of Swallowing and Voice Function With Ileocolon Free Flap

BACKGROUND

Free ileocolon flap is a reliable technique allowing simultaneous restoration of swallowing and speech. The aim is to report our 6-year experience in a single center.

METHODS

Thirty-seven patients treated between 2010 and 2015 were included in the study. Swallowing and speech function were evaluated in 27 patients with a 7-point and 5-point Likert scale, respectively. Moreover, 12 of them consented to voice spectrum analysis (VSA).

RESULTS

Complications noted were: aspiration (3), esophagocutaneous fistula (2), and stricture (1). Seven patients experienced self-limited diarrhea. Regarding swallowing function, 77.8% scored ≥5 on Likert scale whereas speech Likert scale showed excellent results (score >12) in 74%. VSA demonstrated mean phonation time of 10.75 seconds, mean frequency of 131 Hz and mean dynamic range of 56 dB.

CONCLUSION

In experienced hands, the ileocolon flap is safe and effective, particularly in patients with long-life expectancy, providing good swallowing and speech function without further procedures/prostheses.

Modified distal anastomosis between colon and thoracic esophagus for hypopharynx reconstruction using free colon flap: A comparison study

BACKGROUND

Free colon flap is the preferred method of hypopharynx reconstruction when the defect is substantial, or simultaneous voice reconstruction is planned. Most of the complications in free colon flaps are located at the anastomosis between colon and thoracic esophagus due to size mismatch of the lumen. We present our experience comparing a modified anastomosis technique and a conventional anastomosis technique at the distal end of interposed colonic segment.

METHODS

In this retrospective review, 94 patients, divided into two groups, underwent hypopharynx reconstruction. Group A (18 patients), conventional anastomoses between colon and thoracic esophagus was performed, while in Group B (76 patients), underwent the modified method of anastomosis.

RESULTS

The average follow-up period was 46 months in group A and 54 months in group B. Fistula formation was found in 2 patients from Group A, and 1 patient from Group B. Strictures were observed in 4 patients from Group A, and 1 patient from Group B. Difference between both groups regarding complications of leakage and stricture formation was statistically significant (p < 0.05).

CONCLUSION

Modified method for anastomosis between colon and thoracic esophagus was found to be effective in the reduction of complications associated with the use of a free colon flap for hypopharyngeal reconstruction. Further advances of this technique could gain momentum in the future.

Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study

PURPOSE

Surgical complications after total laryngopharyngectomy (TLP) are common, reconstruction is challenging, and patients often lose their ability to swallow and speak. To evaluate these aspects, we analysed outcome after TLP.

METHODS

We reviewed all patients who underwent TLP and subsequent circumferential pharyngeal reconstruction through 2004-2017 at the Helsinki University Hospital.

RESULTS

For the 26 eligible patients, TLP was the primary treatment for 11 and salvage surgery for 15, followed by reconstruction with free flaps in 22 patients and pedicled flaps in 4. An early (≤ 30 days) pharyngocutaneous fistula developed in seven patients (27%; median time 13 days; range 6-26), and a late (> 30 days) fistula in five patients (19%; median time 370 days; range 46-785). In addition, ten patients (39%) developed an oesophageal stricture. Four patients (15%) resumed full oral feeding. A speech prosthesis was inserted for 15 patients (58%) and most of them could produce intelligible speech. We found acceptable survival figures for patients undergoing TLP both as a primary treatment and as salvage procedure: the overall survival at 1 year was 82% and 67%, and at 5 years 33% and 27%, respectively. Disease-specific survival at 1 year was 90% and 70%, and that at 5 years was 45% and 43%, respectively.

CONCLUSIONS

Despite fair survival, TLP carries a high risk for postoperative complications with limited functional outcome, thus necessitating cautious patient selection and surgical experience.

Pharyngeal Reconstruction with Microvascular Free Tissue Transfer

Reconstruction of pharyngoesophageal defects after total laryngectomies and extirpation of hypopharyngeal and upper esophageal carcinomas presents a challenging task. Goals of reconstruction include adequate voice rehabilitation and restoration of normal swallowing. The reconstructive armamentarium contains many options for reconstruction and creation of a new upper digestive tract. This review article focuses on the most commonly used free tissue transfer options for the reconstruction of these defects, with an assessment of their advantages and disadvantages.

Determinants of Free Fasciocutaneous Flap Outcomes in Partial Hypopharyngeal Defects

BACKGROUND

Most of the patients with hypopharyngeal cancer are still diagnosed with advanced stage, and total or partial pharyngectomy with free flap reconstruction is the mainstay of treatment. The aim of this study was to find out the possible risk factors related to surgical complications after free fasciocutaneous flap reconstruction for partial pharyngeal defect and its sequelae in the follow-up.

PATIENTS AND METHODS

We retrospectively reviewed the charts of patients with advanced hypopharyngeal cancer who received free fasciocutaneous flaps for partial pharyngeal defects reconstruction. From 2005 to 2015, 79 free fasciocutaneous flaps (59 free fasciocutaneous flaps and 20 anterolateral thigh flaps) were performed in our department. The risk factors for free flap outcome and complications were evaluated with multivariant linear regression model.

RESULTS

The mean age of patients was 60.8 years with male predominance. The mean follow-up duration was 39.6 months. Most of the cases (97.5%) were in stage III or IV. Patients with comorbidities showed significant correlation to flap failure (95% confidence interval [CI] = 0.038 to 0.264, P = 0.10). Anastomosis style (end-to-side vs end-to-end) was the only operation-related factors significantly related to flap failure rate (18.8% vs 3.2%, 95% CI = 0.031 to 0.32, P = 0.18). Flap size was significantly associated with fistula formation (95% CI = -0.005 to 0.000, P = 0.38).

CONCLUSIONS

In our experience, patients with comorbidities and end-to-side anastomosis illustrate significantly higher flap failure rate in free fasciocutaneous flap reconstruction of partial hypopharyngeal defect. Reconstruction with smaller flap size had higher possibility of fistula formation.

Radial forearm free flap as the last resort for oesophageal reconstruction

Strategies for oesophageal reconstruction following resection vary according to the nature of the pathology encountered, patient factors and surgeon preference. However, reconstruction in patients with multiple previous failed attempts poses specific management challenges. We present the case of a 61-year-old man who underwent oesophageal reconstruction with a radial forearm flap as a last resort.

A Novel Application of Double-Paddle Peroneal Chimeric Flap as External Sentinel Monitor in Hypopharyngeal Reconstruction

OBJECTIVES

Monitoring the viability of buried free flaps in hypopharyngeal reconstruction is difficult. Various methods have been proposed to monitor these buried flaps, but limitations remain.

METHOD

We present a method of using double-paddle chimeric peroneal flaps that permanently externalizes a flap skin paddle as a monitoring paddle in hypopharyngeal reconstructions. This study was performed in a medical center in southern Taiwan; between 2013 and 2015, 10 patients underwent double-paddle chimeric peroneal flap reconstruction in advanced stages of hypopharyngeal cancer. We retrospectively reviewed the medical records from these surgeries, searching for either short-term postoperative complications or long-term follow-up morbidity and researched relevant articles for comparisons with other monitoring methods.

RESULTS

None of the 10 flaps underwent total loss. The rate of stenosis and that of fistula formation was 10%. The average postoperative hospital stay was 39 days. Six of 10 patients were able to resume at least a soft diet after reconstruction, and none of the patients experienced significant complications.

CONCLUSIONS

The peroneal flap is a useful flap because it is thin and pliable, has minimal donor site morbidity in patients without peripheral vascular disease, and has the potential of multiple skin paddles so that one skin paddle can be used for monitoring the buried flap. Using this method, direct clinical monitoring is feasible, and early detection of vascular complications is possible. Furthermore, the drawbacks of using a monitoring paddle produced by a deepithelialized bridge can be avoided.

A Novel Funnel-Shaped Flap for Reconstruction Surgery after Total Laryngopharyngectomy with Total Glossectomy

Reconstruction following total laryngopharyngectomy with total glossectomy (TLPTG) is challenging. To reconstruct this extended range of mucosal defect, it is necessary to overcome the remarkable discrepancy of apertures of oral and esophageal sides. We report a case of reconstruction surgery for total laryngopharyngectomy with total glossectomy with a funnel-shaped rectus abdominis musclocutaneous flap. The patient recovered without major complications and could keep a relatively good swallowing function. We believe this simple method should contribute to cases with complicated ablation.

Revisiting the gastric pull-up for pharyngoesophageal reconstruction: A systematic review and meta-analysis of mortality and morbidity

Gastric pull-up (GPU) is among the oldest techniques for reconstructing the pharyngoesophageal junction following cancer resection. This review examines morbidity and mortality rates following GPU pharyngoesophageal junction reconstruction from 1959 until present: 77 studies, 2,705 patients. The odds of mortality, anastomotic complications, and other complications decreased by 37.2% (95%CI = 28.0-45.3%; P < 0.0001), 8.0% (95%CI = -2.1 to 17.1%; P = 0.12), 21.0% (95%CI 3.5-35.2%; P = 0.021) per decade respectively. J. Surg. Oncol. 2016;114:907-914. © 2016 Wiley Periodicals, Inc.

Functional outcome after one-stage flap reconstruction of the hypopharynx following tumor ablation

The main objective of this study was to evaluate functional outcome in terms of food passage of the three different reconstruction techniques that are currently most often used for hypopharyngeal reconstruction in our institution. A retrospective observational database research was conducted of all patients that underwent hypopharyngeal reconstruction for carcinoma of the hypopharynx or larynx from 1992 until 2014 in the University Medical Center Groningen. The following techniques were most commonly used and therefore analyzed: the pedicled pectoralis major flap, the radial forearm free flap and the anterolateral thigh free flap. Our primary outcome food passage was measured after 1 year and classified in gastric tube fed, fluids, semisolid or solid. Complications were registered according to the Clavien Dindo classification in five different grades. Comorbidity was scored using the Adult Comorbidity Evaluation Index. 58 patients were included. 51 patients survived one year follow up, 25 % returned to a solid diet, 40 % returned to a semi-solid diet and 20 % remained feeding tube dependent. Overall flap success rate was 88 and 35 % developed a pharyngocutaneous fistula. Multivariable ordinal regression showed that reconstruction with free flaps, a near-circumferential surgical defect, a higher body mass index and no comorbidity showed significantly better functional outcomes in the food passage. For recipient site complications, both free flaps and a shorter surgery time resulted in less severe complications. This study shows that the use of free flaps is superior to the use of the pectoralis major flap, and that it should therefore be reserved as a second choice.

The Use of the Sternocleidomastoid Flap Helps Reduce Complications After Free Jejunal Flap Reconstructions in Total Laryngectomy and Cervical Esophagectomy Defects

PURPOSE

Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.

METHODS

A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.

RESULTS

Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.

CONCLUSION

Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.

Chimeric Anterolateral Thigh Flap for Total Thoracic Esophageal Reconstruction

Gastric pull-up is generally the first choice for a total thoracic esophageal reconstruction. Malfunction of this gastric conduit is uncommon, but devastating when it occurs: it causes marked comorbidity to the patient, preventing oral intake and worsening quality of life. Secondary salvage thoracic esophageal reconstruction surgery is usually performed with free or pedicled jejunum flaps or colon interposition. We present a case of a total thoracic esophageal reconstruction with an externally monitored chimeric anterolateral thigh flap, extending from the cervical esophagus to the retrosternal gastroplasty remnant. Intestinal reconstructive techniques were not an available option for this patient.

Delayed reconstruction of the upper digestive tract in a patient following total pharyngolaryngectomy with resection of the cervical oesophagus

Carcinoma of the hypopharynx is an uncommon disease, with an annual incidence of approximately 1 in 100,000. Post-cricoid carcinoma is more common in women and is not usually associated with tobacco and alcohol abuse. Reconstruction of large pharyngeal defects following surgery for squamous cell carcinoma is complex and often requires microvascular free tissue transfer to achieve the best oncological and functional outcomes. The most common complications of such procedures include fistulas and strictures of the neopharynx. Here, we describe a case of a female patient admitted to the Head and Neck Department at our hospital to undergo delayed reconstruction following pharyngolaryngectomy and removal of the cervical oesophagus. Several complications occurred during post-operative care, including stricture and skin dehiscence. At present, the patient is able to swallow saliva and is currently being prepared to return to a normal diet.

Choice of flap affects fistula rate after salvage laryngopharyngectomy

Due to the significant morbidity and mortality associated with pharyngocutaneous fistula in pharyngoesophageal reconstruction following cancer resection, the purpose of this retrospective study is to examine the selection of tubed skin flaps that impact anastomotic integrity. The flaps evaluated included radial forearm flap versus anterolateral thigh flap, and fasciocutaneous anterolateral thigh flap versus chimeric anterolateral thigh flap. The outcome of interest is the incidence of pharyngocutaneous fistula. The radial forearm group had a significantly higher rate of fistula than the anterolateral thigh group (56.6% vs. 30.2%, p = 0.03). No significant difference in the incidence of fistula was demonstrated between fasciocutaneous and chimeric anterolateral thigh flap (36.8% vs. 25%, p = 0.51). The anastomotic integrity in pharyngoesopharyngeal reconstruction is affected by choice of skin flaps. Anterolateral thigh flap appears to be a viable option for pharyngoesophageal reconstruction. The more technical demand of the anterolateral thigh flap must be weighed against an easily harvested radial forearm flap.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach

BACKGROUND

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery.

METHODS

A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference.

RESULTS

Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes.

CONCLUSIONS

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.

Successful management of the cervicothoracic esophagus reconstruction by expanded skin flap

The limited availability of reconstruction materials can often make it difficult to treat defects in the esophagus caused by necrosis of the transplanted intestinal tissue after cervicothoracic esophagus reconstruction. We were forced to perform flap reconstruction on a patient who suffered necrosis due to impeded blood flow of the transplanted intestinal tract after twice conducting cervicothoracic esophagus reconstruction with an intestinal tract flap. The procedure we performed was esophagus reconstruction using a pectoralis major myocutaneous flap that had been expanded with a tissue expander due to the small volume of tissue available to perform the reconstruction. This case suggested that esophagus reconstruction with a skin flap using a tissue expander should be considered as a possible treatment choice when performing reconstruction of the cervicothoracic esophagus, which requires stable blood flow and a large amount of tissue.

Head and neck reconstruction

Whatever is excisable, is reconstructable! “You excise, we will reconstruct” are the confident words of reconstructive surgeons today. Reconstruction with multiple flaps has become routine. Radial artery (FRAF), Antero lateral thigh (ALT) and Fibula osteo cutaneous flap (FFOCF) are three most popular free flaps which can reconstruct any defect with excellent asthetics and performance. Radial Artery provides thin, pliable innervated skin; ALT large amount of skin & bulk; and FFOCF strong 22 to 25 centimetres of bone and reliable skin paddle. Free flap survival has gone to 98% in most of the renouned institutes and is an established escalator in management of defects.

Free jejunal flap transfer for pharyngoesophageal reconstruction in patients with intestinal malrotation: two case reports

Intestinal malrotation results from failure of intestinal rotation and fixation during fetal life. We report two cases of esophageal reconstruction with free jejunal flaps following total laryngopharyngectomy of hypopharyngeal and cervical esophageal carcinoma in which intestinal malrotation was detected during the jejunal flap harvesting. In both cases, the ligament of Treitz was absent, and the laparotomy incision was thus extended to identify the jejunum. In case 1, harvesting an adequate length of the vascular pedicle of the flap was impossible because of the abnormal position of the pancreas; thus, a jejunal flap of maximal length was harvested for optimal pedicle positioning in the recipient site. In case 2, Ladd's ligament prohibited the release of the jejunum from the ascending colon and required its dissection. Both patients underwent successful reconstruction. When the ligament of Treitz is absent during jejunal flap harvesting, investing the whole bowel by extended laparotomy incision is recommended. When anatomical abnormality caused by intestinal malrotation is detected, releasing an adhesion of the jejunum from circumferential organs and identifying the adequate vascular pedicle of a jejunal flap are necessary. If harvesting the long vascular pedicle is impossible, a jejunal flap of maximal length should be harvested for optimal positioning for vascular anastomosis at the shortest distance in the recipient site.