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Smith S, Lee Y, Borrowdale R, Thorpe E, Pittman A. Institutional experience with total pharyngectomy reconstruction: Exploring the role of the salivary bypass tube. Head Neck 2024; 46:721-727. [PMID: 38165002 DOI: 10.1002/hed.27610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND There is a lack of consensus regarding the effectiveness of salivary bypass tubes during total pharyngectomy reconstruction to prevent pharyngocutaneous fistula or pharyngoesophageal stricture. METHODS Our study examined tubed free flap reconstruction outcomes for total pharyngectomy defects over 11 years at a single tertiary referral center. We compared postoperative fistula and stricture rates between two groups: those with salivary bypass tubes inserted during reconstruction and those without. RESULTS Among 36 patients, 26 had radial forearm, and 10 had anterolateral thigh free flap reconstruction. 53% received salivary bypass tubes. However, the tubes did not significantly reduce the relative risks of fistula or stricture. Notably, neck dissection during total pharyngectomy was associated with increased fistula incidence. Minor salivary bypass tube-related complications affected 21% of subjects. CONCLUSION The role of salivary bypass tubes in total pharyngectomy reconstruction remains uncertain.
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Affiliation(s)
- Sullivan Smith
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Yunmin Lee
- Loyola University Stritch School of Medicine, Maywood, Illinois, USA
| | - Richard Borrowdale
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Eric Thorpe
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Amy Pittman
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
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Ignacio LB, Marisol GG, Cristina OFM, Armando UBD, Fernando DMA. Pharyngoesophageal Reconstruction with A Tubed Radial Forearm Free Flap: A Case Report. World J Plast Surg 2024; 13:77-81. [PMID: 39193236 PMCID: PMC11346689 DOI: 10.61186/wjps.13.2.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/27/2024] [Indexed: 08/29/2024] Open
Abstract
Hypopharyngeal carcinoma is one of the most aggressive primary head and neck cancers, often managed through partial or total laryngopharyngectomy. Reconstruction after such surgeries remains a challenging procedure that often requires the use of free flaps. A 63-year-old male patient with in-situ squamous cell carcinoma of the left vocal cord treated with total pharyngolaryngectomy and primary reconstruction with a left radial forearm free flap, complicated by flap necrosis, which ended up in dismantling and gastrostomy. He was referred to the Plastic and Reconstructive Surgery Department at Centro Medico Nacional 20 de Noviembre, Mexico in 2023 to assess the reconstructive options for the hypopharynx and cervical esophagus defect. A tubular right radial forearm free flap was designed forming the anterior wall of the hypopharynx and cervical esophagus and a posterior wall for the external defect. Twelve months after his surgery, he continues tolerating oral intake without signs of stenosis or tumor recurrence. The objective in this case was based on restoring the continuity of the digestive tract and swallowing function, as well as providing skin coverage of the defects, and preventing serious complications. The radial forearm free flap has versatility in the tubular construction and a low leak rate, as well as an adequate skin island size. Conclusion: The pharyngoesophageal reconstruction with a tubed forearm free flap has favorable outcomes for restoring the gastrointestinal tract without further complications.
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Ishida K, Hirayama H, Kishi K, Miyawaki T. Long-term surgical and functional outcomes after anterolateral thigh flap and free jejunal transfer reconstruction of circumferential pharyngoesophageal defects. Head Neck 2023; 45:2996-3005. [PMID: 37755124 DOI: 10.1002/hed.27526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/20/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Circumferential pharyngoesophageal defects resulting from total pharyngolaryngectomy are commonly reconstructed using free jejunal (FJ) transfer or an anterolateral thigh (ALT) free flap. METHODS We reviewed the medical records of 92 patients with ALT free flaps and 140 who underwent FJ transfer between 2009 and 2022, and compared their surgical outcomes. RESULTS Total flap loss occurred in two (2%) and five (4%) patients in the ALT free flap and FJ transfer groups, respectively. Fistula rates were 5% in both groups. Stricture rates were 21% and 5% in the ALT free flap and FJ transfer groups, respectively (p < 0.01). At the 5-year follow-up evaluation, intelligible speech was achieved by 83% and 28% of patients (p < 0.01) in the ALT free flap and FJ transfer groups, respectively. CONCLUSIONS Each reconstructive method can be further optimized by proficient surgeons with expertise in the available methods and by considering patient-specific factors and available evidence.
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Affiliation(s)
- Katsuhiro Ishida
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruyuki Hirayama
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keita Kishi
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Miyawaki
- Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Gur E, Tiftikcioglu YO, Kuybulu TF, Turhal G, Ozturk K. The use of chimeric-superthin anterolateral thigh flap in reconstruction of laryngopharyngoesophagectomy defects of hypopharyngeal cancer. Microsurgery 2023; 43:563-569. [PMID: 36752585 DOI: 10.1002/micr.31021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/19/2022] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Due to 3D defects after resection of hypopharyngeal cancers, free flaps have become as first option for reconstruction and the anterolateral thigh flap (ALT) has been chosen frequently for soft tissue defects. Chimerization of the skin island of the ALT is also possible which can result in reconstruction of multiple defects simultaneously and monitorization of buried flaps. However, ALT can be bulky in some patients. The superthin ALT is well established by some authors especially for extremities but there is no study about the use of this modification in pharyngoesophageal defects. We present our experience of using chimeric-superthin ALT for pharyngoesophageal reconstructions. PATIENTS AND METHODS Between 2019 and 2022, six patients (one female and five male) underwent hypopharyngeal tumor resection and experienced chimeric-superthin ALT flap reconstructions. Patients' ages were ranged between 53 and 71 (mean: 64) years old. The type of tumor was squamous cell carcinoma (SCC) for all patients. Three patients had total and three patients had 75% of pharyngoesophageal defects. Defect size was between 10 × 7 cm and 12 × 8.5 cm (mean: 87.08 cm2 ). All flaps were harvested as 5 mm thickness with two skin perforators. All flaps were divided into two individual skin islands as chimeric fashion. One of the skin islands was used for esophageal reconstruction and the other was used for both flap monitorization and tensionless closure of anterior neck skin. RESULTS Total flap size was between 18 × 9 cm and 21 × 11 cm (mean: 200 cm2 ). In two patients, anastomoses were performed to pectoral branch of thoracoacromial vessels. Neck vessels were chosen as recipient for remaining patients. Wound dehiscence occurred in two patients between the neck skin and monitor island and was re-sutured without any problems. There was no partial or total flap necrosis and all flaps survived. The follow up period was between 4 and 9 months (mean: 5.6). All patients had a successful functional outcome as swallowing. CONCLUSION The superthin-chimeric ALT flap is a useful option when classical ALT is bulky in defects of hypopharyngeal cancer.
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Affiliation(s)
- Ersin Gur
- Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yigit Ozer Tiftikcioglu
- Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Turgut Furkan Kuybulu
- Department of Plastic Reconstructive and Aesthetic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Goksel Turhal
- Department of Ear, Nose and Throat, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kerem Ozturk
- Department of Ear, Nose and Throat, Ege University Faculty of Medicine, Izmir, Turkey
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Lee ZH, Hanasono MM. Pharyngeaoesophageal Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00062-2. [PMID: 37221117 DOI: 10.1016/j.otc.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Pharyngoesophageal reconstruction is one of the most challenging reconstructive dilemmas that demands extensive planning, meticulous surgical execution, and timely management of postoperative complications. The main goals of reconstruction are to protect critical blood vessels of the neck, to provide alimentary continuity, and to restore functions such as speech and swallowing. With the evolution of techniques, fasciocutaneous flaps have become the gold standard for most defects in this region. Major complications include anastomotic strictures and fistulae, but most patients can tolerate an oral diet and achieve fluent speech after rehabilitation with a tracheoesophageal puncture.
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Affiliation(s)
- Z-Hye Lee
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Matthew M Hanasono
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Varghese BT. Survival and Quality of Life (QoL) Enhancing Effect of Surgery in Larynx and Hypopharynx Cancers. Indian J Surg Oncol 2022; 13:888-889. [PMID: 36687242 PMCID: PMC9845434 DOI: 10.1007/s13193-022-01596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023] Open
Abstract
The critical role of surgery in the overall management of larynx and hypopharynx cancers continues to be undermined in all major outcome studies worldwide. This article is aimed at dissecting this aspect and recommends the inclusion of data of all surgical interventions performed on the patients when major clinical trials on larynx and hypopharyngeal cancers are conducted and analysed.
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Affiliation(s)
- Bipin T. Varghese
- Department of Surgical Services, Regional Cancer Centre & Honorary Consultant Head and Neck Surgical Oncologist, Sree Chitra Tirunal Institute for Science and Technology (SCTIMST), Thiruvananthapuram, 695011 Kerala India
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Clinical outcomes following pharyngolaryngectomy reconstruction: a 20-year single-centre study. The Journal of Laryngology & Otology 2022; 136:1105-1112. [DOI: 10.1017/s0022215122000019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
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.
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Kremer T, Gazyakan E, Maurer JT, Ott K, Gerken A, Schmittner M, Ronellenfitsch U, Kneser U, Nowak K. Intra- and Extrathoracic Malignant Tracheoesophageal Fistula-A Differentiated Reconstructive Algorithm. Cancers (Basel) 2021; 13:cancers13174329. [PMID: 34503134 PMCID: PMC8430587 DOI: 10.3390/cancers13174329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients. PATIENTS AND METHODS 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, n = 1), jejunum (n = 3) or combined ALT-jejunum flaps (n = 2). RESULTS Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF. CONCLUSION TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.
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Affiliation(s)
- Thomas Kremer
- Burn Center, Department of Plastic and Hand Surgery, St. Georg Clinic, 04129 Leipzig, Germany
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany; (E.G.); (U.K.)
- Correspondence: ; Tel.: +49-341-9092555; Fax: +49-341-9092291
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany; (E.G.); (U.K.)
| | - Joachim T. Maurer
- Mannheim University Medical Center, Department of Ear, Nose and Throat Surgery, 68167 Mannheim, Germany;
| | - Katja Ott
- Department of General, Vascular and Thoracic Surgery, RoMed Klinikum, 83022 Rosenheim, Germany; (K.O.); (K.N.)
| | - Andreas Gerken
- Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany; (A.G.); (U.R.)
| | - Marc Schmittner
- Mannheim University Medical Center, Department of Anesthesia and Critical Care Medicine, 68167 Mannheim, Germany;
| | - Ulrich Ronellenfitsch
- Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany; (A.G.); (U.R.)
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle (Saale), 06120 Halle, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University Heidelberg, 67071 Ludwigshafen, Germany; (E.G.); (U.K.)
| | - Kai Nowak
- Department of General, Vascular and Thoracic Surgery, RoMed Klinikum, 83022 Rosenheim, Germany; (K.O.); (K.N.)
- Mannheim University Medical Center, Department of Surgery, 68167 Mannheim, Germany; (A.G.); (U.R.)
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Sahovaler A, Gualtieri T, Lee JJW, Eskander A, Deutsch K, Rashid S, Orsini M, Deganello A, Davies J, Enepekides D, Higgins K. Applications of intraoperative angiography in head and neck reconstruction. ACTA ACUST UNITED AC 2021; 41:215-220. [PMID: 34264914 PMCID: PMC8283404 DOI: 10.14639/0392-100x-n1161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/20/2020] [Indexed: 11/23/2022]
Abstract
Objective Laser-assisted angiography with indocyanine green (LAIG) allows objective intraoperative evaluation of tissue vascularity. We endeavored to describe our experience with this technique in the head and neck region. Methods A retrospective review from February 2016 till October 2018 was conducted. We included patients who underwent head and neck procedures in which LAIG was employed. The main outcome was postoperative wound complications. We analysed the influence of LAIG results in intraoperative decision-making process. Results Nineteen patients were included, and follow-up was for at least 6 months. LAIG was employed in 11 local flaps, 9 free flaps and 6 cases of pharyngeal closure during total laryngectomies. Wound complications occurred in two cases with distal tip flap necrosis. LAIG findings resulted in changes in decision making intraoperatively in 84% of procedures, which consisted in trimming poorly perfused tissues. There were no pharyngocutaneous fistulas. Conclusions This represents a descriptive report on the use of LAIG on diverse head and neck reconstruction cases, with important impact on the decision-making process. A low number of postoperative wound complications were observed.
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Affiliation(s)
- Axel Sahovaler
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada.,Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Tommaso Gualtieri
- Guided Therapeutics (GTx) Program, Techna Institute, University Health Network, Toronto, Ontario, Canada.,Unit of Otorhinolaryngology - Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - John J W Lee
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sabrina Rashid
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mario Orsini
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alberto Deganello
- Unit of Otorhinolaryngology - Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Joel Davies
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Danny Enepekides
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kevin Higgins
- Department of Otolaryngology - Head and Neck Surgery and Surgical Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Chen DW, Ellis MA, Horwich P, Sandulache VC, Liou NE, Hernandez DJ, Sturgis EM, Graboyes EM, Hornig JD, Day TA, Huang AT. Free Flap Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function. Laryngoscope 2020; 131:E875-E881. [PMID: 32833308 DOI: 10.1002/lary.28939] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/19/2020] [Accepted: 06/25/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. METHODS Retrospective review. RESULTS Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). CONCLUSION Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E875-E881, 2021.
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Affiliation(s)
- Diane W Chen
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Mark A Ellis
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Peter Horwich
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Vlad C Sandulache
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Nelson E Liou
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - David J Hernandez
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Erich M Sturgis
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Joshua D Hornig
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Terry A Day
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Andrew T Huang
- Department of Otolaryngology-Head & Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
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Caliceti U, Sgarzani R, Cipriani R, Cantore S, Contedini F, Pinto V, Gelati C, Piccin O. Single stage reconstruction of complex head and neck defects involving the skin with a single ALT flap: A ten year review. JPRAS Open 2019; 22:55-64. [PMID: 32158897 PMCID: PMC7061564 DOI: 10.1016/j.jpra.2019.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022] Open
Abstract
Background Multicomponent defects of the head and neck involving the cervical skin pose a reconstructive challenge for microsurgeons and usually requires two flaps. However, many patients who undergo such surgical treatment had prior treatment with radiotherapy and the availability of recipient vessels for free flap reconstruction may be limited. The purpose of this study was to review our experience in the reconstruction of these extensive head and neck defects using a single ALT free flap. Methods A total of 21 patients with complex defects of the head and neck involving multiple anatomical subunits, including the overlying cervical skin, underwent reconstruction with a single ALT flap. The clinical, functional, and aesthetic outcomes of these patients were reviewed. Results The mean hospital stay was 24 days. There was one total flap loss due to pedicle thrombosis. The patient underwent a further ALT reconstruction with no postoperative complications. Cervical fistulas occurred in three patients, and all fistulas were healed by simple wound packing. Three patients with tracheal defect had a functional tracheostoma with adequate stomal patency. A modified barium swallowing study was performed on each patient, and all of them achieved total oral intake. Among them, two patients tolerated only a pureed diet. Conclusions Complex neck reconstruction can be accomplished with a single ALT flap with good clinical and functional results, minimal morbidity and quick recovery.
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Affiliation(s)
- Umberto Caliceti
- Department of Otolaryngology Head and Neck Surgery, S.Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Rossella Sgarzani
- Department of Emergency, Burn Center, Bufalini Hospital, Azienda USL della Romagna, Cesena, Italy
| | - Riccardo Cipriani
- Department of Plastic and Reconstructive Surgery, S.Orsola-Malpighi University Hospital, via Massarenti 9, 40138 Bologna, Italy
| | - Stefano Cantore
- Department of Otolaryngology Head and Neck Surgery, S.Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Federico Contedini
- Department of Plastic and Reconstructive Surgery, S.Orsola-Malpighi University Hospital, via Massarenti 9, 40138 Bologna, Italy
| | - Valentina Pinto
- Department of Plastic and Reconstructive Surgery, S.Orsola-Malpighi University Hospital, via Massarenti 9, 40138 Bologna, Italy
| | - Chiara Gelati
- Department of Plastic and Reconstructive Surgery, S.Orsola-Malpighi University Hospital, via Massarenti 9, 40138 Bologna, Italy
| | - Ottavio Piccin
- Department of Otolaryngology Head and Neck Surgery, S.Orsola-Malpighi University Hospital, Alma Mater Studiorum University of Bologna, via Massarenti 9, 40138 Bologna, Italy
- Corresponding author.
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Total laryngopharyngectomy with circumferential reconstruction: Helsinki institutional study. Eur Arch Otorhinolaryngol 2019; 276:2577-2584. [PMID: 31240457 DOI: 10.1007/s00405-019-05526-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Abstract
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.
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Sokoya M, Bahrami A, Vincent A, Inman J, Mourad M, Sawhney R, Ducic Y. Pharyngeal Reconstruction with Microvascular Free Tissue Transfer. Semin Plast Surg 2019; 33:78-80. [PMID: 30863217 DOI: 10.1055/s-0039-1677877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
| | - Arash Bahrami
- Department of Otolaryngology Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Aurora Vincent
- Otolaryngology, Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jared Inman
- Department of Otolaryngology Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Moustafa Mourad
- Division of Otolaryngology-Head and Neck Surgery, Metropolitan Hospital, New York, New York
| | - Raja Sawhney
- Department of Otolaryngology-Head/Neck Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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Modified Design of Anterolateral Thigh Flap for Total Pharyngolaryngectomy Reconstruction: A Single-Center Experience. Ann Plast Surg 2018; 81:62-67. [PMID: 29762451 DOI: 10.1097/sap.0000000000001480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Defects after total pharyngolaryngectomy for hypopharyngeal cancer often require reconstruction via free tissue transfer. Recently, anterolateral thigh (ALT) flap has become the gold standard in many centers because of its advantages with respect to versatility, minimal donor-site morbidity, good speech quality, and relatively low fistula and anastomotic leakage rates. Moreover, ALT allows 2 surgical teams to work simultaneously. However, the height of the parallelogram in the ALT design for neoesophagus reconstruction is usually set at a minimum of 9.4 cm (circumference, 2πr) for smooth food passage. Because this height exceeds 8 cm, the donor site may not be closed primarily, which highly depends on the patient's body habitus and the skin tone or quality and requires other methods, such as local flap or skin graft for wound closure, which subsequently increase operating time and donor-site complication rate. OBJECTIVES Thus, we aimed to construct a simple and modified ALT design that will not only include the advantages described earlier but also provide adequate donor-site primary closure without jeopardizing complication rates. METHODS Ten patients with hypopharyngeal cancer underwent reconstructive surgery using our modified ALT design after total pharyngolaryngectomy between 2010 and 2017. Our modified ALT design converts this "classical" shape into a parallelogram so that the height of the modified design is always less than 8 cm, thus allowing for easy primary closure of the wound. RESULTS The donor-site defects of all 10 patients were closed primarily. No donor-site complications and partial or total flap loss were observed. One patient experienced persistent wound infection with dehiscence, for which debridement was performed. The stricture and fistula rates were 10% (n = 1) and 20% (n = 2), respectively. The mean follow-up time is approximately 1 year. CONCLUSIONS Minimizing donor-site morbidity is an important goal in reconstructive surgery. Our modified ALT flap design is simple, enabling easy primary closure of the donor-site defect, with improved results for the patient and operators. Furthermore, this design is also suitable for ALT flaps with widths larger than 8 cm.
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Shoulder Morbidity in Patients after Head and Neck Reconstruction with the Pedicled Supraclavicular Island Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1711. [PMID: 29876164 PMCID: PMC5977956 DOI: 10.1097/gox.0000000000001711] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 12/19/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The pedicled supraclavicular artery island flap (SCAIF) for reconstruction of the head and neck has been shown to be a pliable alternative to established pedicled flaps, such as the pectoralis major myocutaneous flap. Because there are limited published data regarding shoulder morbidity after SCAIF procedure, we aimed to investigate it with 2 established questionnaires for the upper extremity [Constant-Murley score and Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) score]. Methods: The authors designed and implemented a retrospective cohort study of patients who received a defect reconstruction by SCAIF. Analyzed parameters were demographics, comorbidities, donor-site morbidity and shoulder morbidity in terms of range of motion, pain, strength, and daily activities evaluated and compared between the donor site and contralateral arm. Results: Of the 61 consecutively performed head and neck reconstructions with SCAIF, 20 met inclusion criteria (curative intended treatment, head and neck squamous cell cancer, follow-up time more than 4 months). Mean follow-up was 17.3 months (±10.4 months) ranging from 4–35 months. Donor-site complication rate was low with 5% major (surgical revision) and 30% minor complications (conservative management). Overall Constant-Murley-Score (P = 0.334), pain (P = 0.150), overall range of motion (P = 0.861), and strength of the extremity (P = 0.638) of the shoulder receiving a SCAIF showed no significant differences to the contralateral extremity. Mean of Disabilities of the Arm, Shoulder and Hand Outcome Measure score was 32.5 (±28.6). Conclusion: The results of the present study suggest very low shoulder morbidity in patients after SCAIF procedure with no significant functional impairment of the donor shoulder compared with the contralateral side.
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Optimizing Outcomes in Pharyngoesophageal Reconstruction and Neck Resurfacing: 10-Year Experience of 294 Cases. Plast Reconstr Surg 2017; 140:763e. [PMID: 29068963 DOI: 10.1097/prs.0000000000003796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Single-stage reconstruction of combined hypopharyngeal and anterior neck skin defects with the dual-paddle anterolateral thigh flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017. [DOI: 10.1007/s00238-017-1366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Optimizing Outcomes in Pharyngoesophageal Reconstruction and Neck Resurfacing: 10-Year Experience of 294 Cases. Plast Reconstr Surg 2017; 140:636e-638e. [PMID: 28953750 DOI: 10.1097/prs.0000000000003727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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