Comparison of voice outcomes after radial forearm free flap reconstruction versus primary closure after laryngectomy.

OBJECTIVE: Laryngectomy with primary closure and tracheoesophageal prosthesis (TEP) voice rehabilitation has been the mainstay of the management of patients with advanced laryngeal malignancy. When adequate mucosal tissue is not available, pharyngeal reconstruction with free flaps can be utilized. The speech outcomes of these patients have been traditionally considered inferior based on the findings of a limited number of studies. We report the results of a review of our experience with radial forearm free flap (RFFF) reconstruction of extensive laryngopharyngectomy defects vs our institutional outcomes seen with primary closure. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: All patients treated with laryngectomy procedures with either primary closure (28 patients) or RFFF (20 patients) reconstructions at the Cleveland Clinic from 2002 through 2007 were included. Blinded evaluation with statistical analysis of standard speech outcomes measures (maximal sustained phonation, fluent count) as well as qualitative variables are reported. RESULTS: Based on our data collection, the two groups are statistically indistinguishable. CONCLUSIONS: These findings support the utility and effectiveness of the RFFF in pharyngeal reconstruction in achieving good voice outcomes.

Swallowing outcomes after microvascular head and neck reconstruction: a prospective review of 191 cases.

BACKGROUND: The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. METHODS: The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect. RESULTS: The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. CONCLUSIONS: In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.