Clinical application of pedicled chimeric thoracoacromial artery perforator flap for circular hypopharyngeal reconstruction / 中国修复重建外科杂志

Objective: To explore the effectiveness of pedicled chimeric thoracoacromial artery perforator (TAAP) flap as a reconstructive option for circular hypopharyngeal defects. Methods: Between January 2013 and December 2014, the pedicled chimeric TAAP flap was used to repair oncologic circular hypopharyngeal defects in 8 patients, included 6 males and 2 females, with an average age of 57 years (range, 45-80 years). All patients were treated in other hospitals before and recurrence was noted. The duration between latest treatment and recurrence ranged from 3 to 28 months (mean, 16.5 months). According to Union for International Cancer Control (UICC) TNM staged, 3 cases were T 2N 1M 0, 2 cases were T 3N 1M 0, 1 case was T 3N 2M 0, 2 cases were T 4N 1M 0. After laryngectomy, the size of circular hypopharyngeal defect ranged from 9.0 cm×8.5 cm to 12.0 cm×10.5 cm. The size of TAAP flap ranged from 7.0 cm×4.0 cm to 9.5 cm×6.0 cm．The size of pectoralis major flap ranged from 9.0 cm×5.0 cm to 14.5 cm×6.0 cm．The donor sites were closed directly in all cases. Results: Postoperatively all flaps survived smoothly, and all defects healed by first intention. No early complication was noted. The mean hospital stay period ranged from 12 to 22 days (mean, 14.5 days). All patients were followed up 12-45 months (mean, 18.7 months). Patients possessed good appearance of surgical sites. No recurrence, fistulas, stenosis/strictures, dehiscence, or swelling occurred. Only linear scars were left on the donor sites, and the pectoralis major muscle function was completely preserved in all patients. Conclusion: Patients with high comorbidities may not be suitable candidates for free flap reconstruction, especially when the recipient vessels are affected from disease or radiotherapy. Pedicled chimeric TAAP flap is a good choice for the reconstruction of hypopharyngeal defects in such conditions．.

Modified Design of Anterolateral Thigh Free Flap for Hypopharyngeal Reconstruction

PURPOSE: Defect after ablation of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Since neo-hypopharynx is totally buried, various methods have been suggested for monitoring. We propose a modified design of anterolateral thigh (ALT) free flap for reconstruction of pharyngolaryngectomy defect, which has an exteriorized part for clinical monitoring and allows for primary closure. MATERIALS AND METHODS: Three consecutive patients with hypopharyngeal cancer were reconstructed with ALT flap with modified design: 1) distal part of flap was elongated into fusiform shape and used as exteriorized monitoring segment with a deepithelized bridge and 2) proximal part was designed as curve so the maximum width of the flap was reduced to less than 10 cm. RESULTS: Patient 1, 2 had uneventful postoperative course with healthy skin color and fresh pin prick bleeding. In patient 3, defect after cancer ablation was shorter than usual and deepithelized bridge was longer. When the general hemodynamic status of the patient was aggravated in postoperative course, the color of monitoring skin was changed. Viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks and repair was necessary. In all patients the donor sites were closed primarily. CONCLUSION: By the modified design of ALT flap, clinical monitoring can be possible by examining exteriorized monitoring flap and also donor site can be closed primarily. However possibility of false positive exists and technical caution and patient selection is needed because of danger of leakage.

Clinical Experience of Radial Forearm and Anterolateral Thigh Perforator Faciocutaneous Free Flap for Hypopharyngeal Reconstruction

The reconstruction of hypopharynx after ablation of carcinoma is quite challengeable to plastic surgeons and requires the recovery of anatomic continuity and its own function such as swallowing and speech. Various surgical methods have been evolved through the years from local flap to microvascular free flap. The latter, obviously has improved the surgical outcome playing a main role in reconstruction of hypopharynx and universally been divided into visceral free transfer and fasciocutaneous free flap. Though lots of surgical options are reported depending on the shape and size of defect, patient's desires or surgeon's empirical background, no general agreement about the reconstruction of hypopharynx exists because the advantage of the one flap can be a disadvantage of the other and vice versa. The fasciocutaneous free flaps were used for reconstruction of hypopharynx in 18 patients, radial forearm free flap for 14 and anterolateral thigh perforator flap for 4 patients, respectively and indicated following that the first is the patients have partial defect that retain the remnant mucosa more than 50% of hypopharyngeal circumference. the second indication is the patient with previous abdominal operation and the third is the patient with risk of long ischemic time of transferred bowel. the last cases is the elderly patient with other comorbid condition even though the remnant mucosa are less than 50% of hypopharyngeal circumference. We have designed the flap to have a sufficient lumen of neohypopharyngeal diameter more than 4cm and the cephalic margin of hypopharynx be wider than caudal one, like a funnel shape, to eliminate the size discrepancy between the pharyngeal and esophageal lumen. The small triangular flap extension was designed in the caudal margin to prevent the distal enteric anastomosis site from the stricture, making the circumference of distal margin to be enlarged. In this paper, we contemplate our speculation for use of fasciocutaneous free flap for reconstruction of hypopharynx with surgical finesse to get a fine surgical outcome.

Platysma myocutaneous flap for hypopharyngeal reconstruction.

Ten male patients with hypopharyngeal and/or laryngeal cancer underwent hypopharyngeal reconstruction after tumor ablation, using platysma myocutaneous flaps. Their age ranged from 41-82 years, (mean age of 62.7 years). All were examined by barium swallowing before and 2 weeks after operation in order to compare the size and function of hypopharynx. The immediate postoperative period was uneventful and satisfactory except one patient (10%) who suffered from the separation of suture lines on the flap leading to the development of saliva fistula and neck infection. The surgical technique, minor complications and long-term postoperative results were fully described in the report.