Modification of the radial forearm fasciocutaneous flap in partial pharyngolaryngeal reconstruction to minimize fistula formation

Purpose

Reconstruction of pharyngo-laryngo-esophageal (PLE) defects secondary to cancer extirpation is a challenging problem encountered by head and neck surgeons. Potentially devastating adverse consequences of salivary leak, fistula and stricture formation can lead to issues with speech and agglutination as well as delay induction of much needed adjuvant therapies. While smaller defects can be primarily closed, circumferential defects or those involving >50% of the PL require flap reconstruction¹. With increased experience utilizing the fasciocutaneous flaps leading to clever modifications in flap configuration, recent literature has shown more favorable results, without the donor site morbidity associated with visceral flap harvest^2-8.

Methods

We describe a case of reconstruction of a partial PLE defect using a modified RFF with reinforced dermal layer closure. We review the literature for innovations in the use of RFF for reconstruction of these difficult case.

Case report

 

A 76-year-old male presented with a recurrent supraglottic laryngeal squamous cell carcinoma which had been treated in the past with radiotherapy, chemotherapy and a left modified radical neck dissection. He underwent total laryngectomy, cricopharyngeal myotomy, and primary tracheo-esophageal puncture. A trapezoidal left RFF with extra dermal layer was used to reconstruct the resulting defect. He was seen 3 weeks post-surgery and a swallow study showed mildly impaired pharyngeal swallow with mild tracheal aspiration and no leak. His 4 month outcome showed no complications of stricture or fistula formation.

Results and Conclusion

A literature review showed a total of 7 publicaitons providing technical tips that have contributed to reduced stricture and fistula rates. These tips include incorporating triangles of RFF skin at the proximal and distal PLE anastomoses, overlapping dermis, use of a salivary bypass tube and a ‘cork’ type patch repair. ^2,3,5,9.

The RFF is a versatile, reliable flap that has become a ‘go-to’ flap for partial and circumferential PLE reconstruction. While fistula and stricture rates can be high, with the addition of the appropriate modifications the RFF can have complication rates comparable to other highly touted modalities such as the FJF.