Distal skin paddle as a monitor for buried anterolateral thigh flap in pharyngoesophageal reconstruction

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.

Intraoperative salvaging of failure to harvest the bi-paddle anterolateral thigh flap: a case series

Background

The size and versatility of anterolateral thigh (ALT) flap enables a bi-paddle flap to cover complex and extensive defects optimally. However, it is characterized by variations in the sources of blood vessels and in the number of perforators, which increases the chances of failure of harvesting a bi-paddle flap. We present our method to overcome such failure. This is the first study exploring the optimal salvaging algorithm to overcome harvesting failure with the bi-paddle ALT flap.

Methods

From January 2014 to December 2020, in 9 patients to be treated with bi-paddle ALT flap for soft-tissue defects (range, 48–288 cm²), there was failure of flap harvest because of perforator variations. We redesigned and converted the flaps to other forms for harvest intraoperatively, based on the characteristics of the defect, and the number and sources of perforators.

Results

Salvage of flap harvest was successfully performed in all 9 cases. In 4 cases the flap with a single perforator was converted to widened-single-perforator flaps; in 2 cases, a single perforator was converted to a de-epithelialized flap; in 2 cases of 2 perforators from different main branches, conversion was to sequential chimeric flaps; in the remaining case of 2 perforators from the descending branch and transverse branch, conversion was to a combined transverse-and-descending branches flap. Venous compromise occurred in only 1 case, and the patient survived after revised surgery. Local infection in the receiving area occurred in 3 cases, and was cured by wound dressing. All flaps survived (follow-up 5–24 months).

Conclusions

Despite preoperative preparation, anatomic variations resulted in failure of bi-paddle ALT flap harvesting. As shown by our results, it is feasible to redesign and convert the bi-paddle flap to other forms based on the defect characteristics, and the number and sources of perforators.

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.

Pharyngeal reconstruction with a modified free alt flap with parastomal fascial wings

AIM

Previous reports have demonstrated good outcomes with the use of the Anterolateral Thigh Flap (ALT) in pharyngeal reconstruction. We report a new modification of free ALT flap pharyngeal reconstruction utilizing vascularised fascial wings or extensions placed in the parastomal gutters to cover the major neck vessels.

PATIENTS AND METHODS

This was a single-center retrospective case review. Between November 2017 and January 2019, 8 patients (6 male, 2 female mean age 61, range 35 to 74) underwent near circumferential pharyngeal reconstruction by the modified technique. 3 patients had laryngopharyngectomy for radiorecurrent larynx SCC, 2 for primary, advanced laryngeal SCC, and 3 for primary hypopharyngeal SCC.

RESULTS

All eight patients regained adequate swallow to maintain nutrition without tube-feeding. Two of the patients have been assessed as appropriate for tracheo-esophageal puncture and are awaiting placement. One patient uses an electrolarynx for speech and 5 patients aphonic only. One patient died 2 months after the procedure from chest infection. There were no flap failures, no fistulas and no strictures at one year. One patient who underwent a salvage laryngopharyngectomy experienced parastomal wound dehiscence, but critically there was no return to theater for exposed major vessels and the wound healed within 6 weeks requiring dressings only.

CONCLUSION

Here we report outcomes of pharyngeal reconstruction with a modified single perforator free ALT flap using fascial extensions to line the parastomal gutters. In the event of parastomal dehiscence, the placement of vascularized tissue parastomally may facilitate spontaneous healing and prevent major vessel exposure.

Effective Secondary Reconstruction of Refractory Urethrocutaneous Fistula after Metoidioplasty Using Folded Superficial Circumflex Iliac Artery Perforator Flap

Supplemental Digital Content is available in the text.

One of the primary goals of penile reconstruction for female-to-male transsexuals is to enable voiding while standing. Metoidioplasty represents a viable option, but it is associated with a high rate of postoperative fistula formation and recurrence, which affects the aesthetic and functional outcomes. Subsequent surgical repair using scarred and inadequate local tissue may contribute to fistula recurrence. The folded superficial circumflex iliac artery perforator (SCIP) island flap offers sufficient well-vascularized tissue and skin envelope for the reconstruction of the urethra and outer skin after failed metoidioplasty. The SCIP flap can be elevated as a hairless thin flap, making it useful in urethral reconstruction even when it is folded. We describe a case of a 44-year-old female-to-male transsexual patient who developed a refractory urethrocutaneous fistula after metoidioplasty. Surgical repairs were attempted using local tissue 4 times without success. The patient presented to our hospital, and we performed urethral reconstruction using a folded, pedicled SCIP flap for both urethra and skin augmentation. The postoperative course was uneventful, with satisfactory functional results and low donor-site morbidity. No fistula recurrence was observed during the 2 years of follow-up. This novel procedure offers a viable alternative technique for refractory urethrocutaneous fistula repair.

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.

Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

OBJECTIVES/HYPOTHESIS

Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies.

STUDY DESIGN

Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies.

METHODS

Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT.

RESULTS

In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate.

CONCLUSIONS

First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2731-2737, 2017.

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.