The aim of this retrospective study is to review the experience of our institution in performing microvascular head and neck reconstruction between 2000 and 2004. During this period, 213 free flaps, including 146 radial forearm free flaps, 60 fibular flaps and 7 scapular flaps, were performed. Free flap success rate and complications were reported. The pre-treatment factors influencing these results were subsequently analyzed. Functional and aesthetic outcomes were evaluated by the same clinician. There were 14 free flap failures, giving an overall free flap success rate of 93.4%. Salvage surgery for recurrent cancer was the only factor correlated with a higher risk of free flap failure (P = 0.0004). The local complication rate was 20.9%. High level of comorbidity (P = 0.009), salvage surgery for recurrent cancer (P = 0.03) and hypopharyngeal surgery (P = 0.002) were associated with a higher risk of local complications. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results.

Head and neck reconstruction with free flaps: a report on 213 cases

Fasciocutaneous (FC) free flaps are gaining widespread popularity for the reconstruction of head and neck defects. The radial forearm free flap and the anterolateral thigh flap are now widely used for pharyngolaryngo-oesophageal (PLO) reconstruction. In many units these flaps are used in preference to enteric free flap reconstructions. This review examined the literature regarding the morbidity, mortality and functional outcomes of FC free flap reconstruction of PLO defects, particularly with respect to the recent modifications reported in the literature. A Medline search was performed for reports published between 1994 and 2005 and a total of 20 papers were reviewed. Cumulative fistula and stricture rates were 13% and 16.1%, respectively, and many surgeons have incorporated modifications in the technique to further reduce these rates. These results compared favourably to recent reports of enteric reconstructions. Functional outcome with the FC free flaps were superior to those reported with jejunal flaps, especially with regard to speech following tracheo-oesophageal puncture. Following a fasciocutaneous reconstruction, hospital admission time and ICU stay were shorter and there were fewer perioperative deaths. Based on this comprehensive review of the literature with respect to morbidity, mortality and functional outcomes, FC free flap reconstruction of the PLO defect can be considered an excellent first line treatment of these difficult defects.

Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature

Background. This study reports our experience with fasciocutaneous reconstruction of circumferential pharyng- oesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube. Methods. The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included. Results. There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with sali- vary tube migration in the early cases have led to technique refinement. Conclusions. The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combi- nation with a salivary bypass tube a viable option for reconstruc- tion of these difficult defects. V C 2006 Wiley Periodicals, Inc. Head Neck 29: 147-154, 2007

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Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

Objective/Hypothesis: To evaluate risk factors and management options for fistula formation after hypopharyngeal reconstruction using the radial forearm free flap reconstruction.



Study Design: Retrospective cohort study.



Methods: Patients undergoing radial forearm free flap for hypopharyngeal reconstruction were retrospectively reviewed. A total of 104 patients underwent this procedure between 2001 and 2007. Fistulas were classified as mild or severe depending on the response to conservative management. Demographics, operative details, pathology, and postoperative course were recorded as the prognostic variables. Univariate analysis and a logistic regression model were used to identify associated factors.



Results: Pharyngocutaneous fistula developed in 30 (28.8%) patients. Recurrence, cancer stage, cancer location, type of ablative surgery, and the addition of other oncologic procedures were identified as significant predictors of fistula formation. Fistula significantly increases hospital stay and recipient site complications such as flap survival, infection, and bleeding. Functional results such as diet, deformity, and socialization were also negatively affected by fistula development. One third of the cases responded to conservative management, and 20 cases required a surgical procedure to definitively close the fistulous track.



Conclusions: Fistula formation remains a significant cause of morbidity associated with hypopharyngealreconstruction. Postoperative course and successful preventive strategies are discussed.

Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects.

Surgical treatment of hypopharyngeal cancers with extension to the retrocricoid region generally requires a circumferential pharyngolaryngectomy followed by a reconstruction of the removed segment of the upper digestive tract. Historically, many techniques have been used in order to achieve a safe and functional reconstruction. Jejunum interposition is generally considered the best reconstructive technique. This study examines the details of the surgical technique, the complications, the oncological and the functional results in a series of 29 consecutive patients submitted to circumferential pharyngoesophageal resection for advanced hypopharyngeal cancer followed by reconstruction with a free flap of jejunum. Three of the transplants failed because of venous thrombosis. The overall success rate was 90%. There were no general complications. A good swallowing has been preserved in all our patients. All our patients where a phonatory prosthesis was positioned (20/29) were able to achieve speech following speech therapy and all were satisfied with their own capacity to communicate. The prognosis of hypopharyngeal tumours (18–40% at 5 years) remains poor, but jejunum autografts are being shown to be an excellent choice for the reconstruction of the cervical hypopharyngo-oesophagus offering the patient fast rehabilitation and a reasonable quality of survival. Our experience confirm that this kind of reconstruction is safe with a good results in improving oncologic controls and restoring a good quality of life.

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M. Sezgin

Papers

Pharyngoesophageal reconstruction with the tubed radial forearm free flap.