Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

Abstract

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.

Keywords: Hypopharyngectomy; fistula; free flap; reconstruction; stenosis.