Revenaugh PC, Waters HH, Scharpf J, Knott PD, Fritz MA. Suprastomal Cutaneous Monitoring Paddle for Free Flap Reconstruction of Laryngopharyngectomy Defects. JAMA Facial Plast Surg. 2013;15(4):287-291. doi:10.1001/jamafacial.2013.845
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Method of direct clinical monitoring of tissue perfusion in free tissue reconstruction of pharyngeal defects.
To describe a novel and effective method of incorporating a cutaneous skin paddle into laryngopharyngectomy reconstruction for direct clinical monitoring of anterolateral thigh free flaps.
Retrospective review of pharyngoesophageal reconstruction for laryngopharyngectomy defects performed between August 1, 2008, and March 1, 2011, using the anterolateral thigh flap.
Tertiary care academic medical center.
Consecutive patients undergoing laryngopharyngectomy where free tissue transfer is indicated.
Anterolateral thigh free flap reconstruction with suprastomal cutaneous monitoring paddle.
Main Outcome Measures
Postoperative complications, including flap failure, fistula, and stricture. Postoperative functional outcomes of swallowing and vocal capability were also measured.
Twenty-one patients (mean age, 62.2 years; range, 39-81 years) underwent total laryngectomy with near-total or total pharyngectomy and immediate reconstruction with an anterolateral thigh free flap. The reconstructions included a cutaneous monitor paddle distal to the pharyngoesophageal anastomosis. Twenty patients were treated for squamous cell carcinoma and received either adjuvant or neoadjuvant radiation therapy. There were no partial or total flap losses. A late pharyngocutaneous fistula occurred at 6 weeks in 1 patient (5%), requiring exploration, and anastomotic stricture occurred in 4 patients (19%). All patients except 1 were able to swallow solid foods at a mean follow-up of 11.1 months. Nineteen patients (90%) underwent tracheoesophageal puncture and attained an intelligible voice. One patient (5%) had stomal stenosis requiring surgical management.
Conclusions and Relevance
The suprastomal cutaneous monitoring paddle enables direct monitoring of an otherwise buried reconstructive flap. This method allows direct clinical observation for microvascular compromise without a need for further procedures and without any increase in morbidity or compromise of speech and swallow functions.
Level of Evidence
Total laryngectomy with partial or total pharyngectomy has been the mainstay of treatment for advanced and recurrent laryngeal and hypopharyngeal squamous cell carcinoma. Advanced tumors or failures after chemoradiation protocols may preclude primary closure owing to lack of tissue or a high risk of pharyngocutaneous fistula.1,2 Microvascular free tissue transfer has quickly become the preferred reconstruction method for such defects. Radial forearm free flaps (RFFFs) and free jejunal transfer have historically been used for laryngopharyngectomy reconstruction,3,4 with anterolateral thigh (ALT) flaps gaining popularity in recent years. This change is due in no small part to the reliability of the flaps, the ease of harvest, and low complication rates.5- 7
Success rates for microvascular free tissue transfer at our institution and across the country approach 99%.8 Despite high success and low complication rates, total or partial flap loss can have devastating consequences. Rates of surgical salvage after flap compromise are only 50%,9 with early identification of microvascular compromise paramount in maximizing salvage potential.
Clinical evaluation of end-organ tissue perfusion is the most direct and reliable method for assessing flap perfusion. Reconstruction of the hypopharynx and esophagus with a fasciocutaneous or enteric free flap necessitates a buried flap, which eliminates the ability to clinically monitor flap perfusion by way of skin appearance, color, turgor, and temperature. Several invasive and noninvasive monitoring devices developed in the past 20 years provide objective data to help assess microvascular perfusion.10- 15 Because of questionable reliability, cost, cumbersome techniques or technology, and even increased complication rates, various proposed techniques have been slow to be adopted at many centers. Clinical evaluation remains the criterion standard for flap monitoring. With this in mind, several techniques to provide tissue-based monitoring segments have been proposed for a number of buried flaps in the head and neck. Criticisms of proposed techniques have included their technical limitations, increased operative time and complexity, and high rates of false-positive findings.16- 24 The need for additional procedures and aesthetic concerns have further limited the utility of these techniques.
We present a novel and technically simple modification of ALT free tissue reconstruction of laryngopharyngectomy defects that permanently externalizes a cutaneous portion of the flap in an aesthetically satisfactory manner, allowing direct clinical monitoring with a low false-positive rate and no need for further removal procedures. The purpose of this study was to retrospectively review our experience with this method in a series of patients, reporting not only flap success but also postoperative functional outcomes.
In a retrospective review at the Cleveland Clinic, 21 patients underwent pharyngoesophageal reconstruction with an ALT flap that included an externally placed cutaneous monitoring paddle superior and posterior to the newly created tracheal stoma. This review was approved by the institutional review board at the Cleveland Clinic. All patients underwent both total laryngectomy and at least partial pharyngectomy with microvascular pharyngeal reconstruction. All patients were evaluated and treated by clinical nutritionists and speech pathologists for perioperative nutritional assessment as well as postoperative swallowing and tracheoesophageal speech production.
A 2-team approach was used in all cases, and the ALT flap was harvested by the reconstructive team during the extirpative procedure as a perforator flap. An incision was planned along the lateral thigh based on anticipated perforator location. At least 2 cutaneous perforators were included in each flap. These were traced to the descending branch of the lateral femoral circumflex artery, with as little dissection of the vastus as necessary.
Once the extirpative defect size was identified, inferior, superior, and lateral cutaneous incisions were performed to create a desired flap size. The tapering, inferior border was extended by 6 to 8 cm to account for the deepithelialized portion as well as the suprastomal cutaneous monitoring paddle, as depicted in Figure 1. Bulkier flaps were thinned before inset, as appropriate. Reconstruction was performed using a single layer of 3-0 polyglactin sutures in an interrupted, horizontal mattress fashion with spatulation of the distal esophageal component of the flap to avoid postoperative stricture. The cutaneous monitoring segment was fashioned into an inverted V or chevron shape to provide posterior stoma height and avoid soft-tissue interference with the stoma. The intervening segment of flap between the distal esophageal anastomosis and the suprastomal cutaneous portion was deepithelialized (Figure 1 and Figure 2).
Stoma vents were used for any patient who had peristomal edema with the potential for airway embarrassment. Tube feeding was started on postoperative day 1 or 2 and continued until clinical swallow evaluation, generally between postoperative days 7 and 20. Patients were permitted to begin weight bearing on the donor leg on postoperative day 1, as appropriate.
All patients were evaluated and treated by clinical nutritionists and speech pathologists for perioperative nutritional assessment as well as postoperative swallowing and tracheoesophageal speech production. Speech assessment and rehabilitation began at the first postoperative visit.
Data were expressed as median or mean (SD) values.
The patients included 18 men (86%) and 3 women (14%), with a median age of 62.2 years (range, 39-81 years). The mean (SD) follow-up was 10.0 (8.6) months. Twenty of 21 patients were treated for squamous cell carcinoma of the larynx or hypopharynx, primary (9 [45%]) or recurrent (11 [55%]); all cases were stage III or IV at the time of surgery. One patient had undergone prior free flap reconstruction and was treated for postoperative stricture not responsive to repeated dilation, 1 was treated for radiation-induced chondronecrosis of the larynx, and 20 patients were treated with radiation therapy, either adjuvant (28%) or neoadjuvant (72%). Major medical comorbid conditions included hypertension (18%), chronic obstructive pulmonary disease (18%), chronic kidney disease (9%), and coronary artery disease (18%).
All defects were circumferential or near circumferential (strip of mucosa, <2 cm wide). The mean flap size was 124.1 cm2, and the donor site was closed primarily in all cases. The median hospital stay was 8 days (range, 6-32 days); 3 patients had extended hospital stays because of medical complications.
There were no instances of flap loss or microvascular compromise. One patient required return to the operating room on the first postoperative day because of a superior flap dehiscence noted at the level of the oropharynx; she had limited native tissue at the superior pharyngeal anastomosis because this was her third free flap reconstruction for recurrent squamous cell carcinoma. There were no instances of esophageal anastomotic dehiscence. One patient was noted to have an anastomotic leak 6 weeks after reconstruction, requiring exploration and a sternocleidomastoid flap.
As reported by other groups, the swallowing6 function was determined by the type of diet tolerated by the patient before progression of disease. Two patients were excluded owing to early recurrence of disease. Of the remaining patients, 18 returned to regular diet with only oral mechanical limitations (ie, the patient was edentulous or had other dental limitations). Four of 21 patients (19%) developed clinical symptoms of dysphagia with stenosis noted at esophagoscopy. One patient remained dependent on a tube feeding despite repeated dilation.
All but 2 patients underwent tracheoesophageal puncture at the time of reconstruction; 18 underwent primary puncture and 1 underwent secondary puncture. There was 1 donor site complication, with breakdown of the incision that resolved with local wound care. No patients subjectively noted weakness or functional deficit in the donor leg.
Reconstruction of total laryngopharyngectomy defects has been revolutionized by the advent of free tissue transfer techniques. Many fasciocutaneous and enteric flap techniques have been described, with varying rates of flap failure, postoperative complications, and postreconstruction swallowing and speech success.7,25 Flaps for many head and neck reconstructive procedures, such as oral cavity and oropharyngeal reconstruction, allow an exposed cutaneous portion of the free flap for the clinician to directly monitor such factors as color, temperature, capillary refill, turgor, and texture. These cutaneous paddles can be used to assess dermal bleeding, and perforating vessels can often be directly evaluated with a handheld Doppler device, giving the clinician more assurance of upstream vessel patency. However, most current techniques of pharyngoesophageal reconstruction require a buried free flap, making direct clinical evaluation difficult. Although bedside nasopharyngoscopy can be used, the evaluation is frequently difficult and limited owing to edema and secretions.
The lack of a simple yet reliable monitoring technique has stimulated technical and operative innovation, with the goal of developing invasive and noninvasive monitoring devices to assess perfusion. Proposed techniques have included internal and external thermometry, color duplex sonography, near-infrared spectroscopy, internal and external Doppler monitoring, microdialysis, and standard pulse oximetry.10- 15
Standard pulse oximetry, external Doppler assessment, and thermometry can be limited by the buried nature of the flap, the interference of other neck vessels with potential false-positive findings, and the skill required to perform the assessments.15,16 Color duplex sonography, near-infrared spectroscopy, and microdialysis are sensitive for detecting microvascular compromise, but their use is limited by the need for specific equipment, system expertise, and high costs.12- 14 Furthermore, these techniques are not well described or validated for buried head and neck flaps. Implantable Doppler devices provide real-time and continuous feedback regarding vessel patency, but they are also limited by their cost, invasive nature, and potential for migration in the neck.10
Other groups have described externalizing some portion of the flap, each technique having its own limitations.16- 22,24 With RFFFs, monitoring techniques using externalized muscle, vessel stumps, or even a separate island flap have not been adopted owing to high complication rates and aesthetic concerns.16,19,21
Furuta et al,24 Akin and Basut,22 and Urken et al23 described a deepithelialized portion of the RFFF, similar to that used in our technique. Each technique was limited by the defined position of the monitoring paddle and the need to take additional forearm skin, restricting the cutaneous portion available for reconstruction. With regard to the ALT flap, there is a paucity of literature describing monitoring efforts.
With the increased use of the ALT flap in head and neck reconstruction, development of an externally placed monitoring paddle would be of clinical benefit. Ferguson and Yu17 compared the use of an externalized flap portion with the use of implantable or handheld Doppler devices and found a 31% false-positive rate for the Doppler devices, leading to unnecessary surgical exploration, as well as 2 unrecognized flap losses. No thromboses or flap losses occurred in their 6 patients who were monitored by using a segment of tissue that was separate from the main flap but shared the same source vessel. However, all patients required a second procedure for removal of the monitoring segment, and no postoperative complications or functional outcomes were reported.
In a technique similar to that described by Yu and colleagues,26 we deepithelialize a portion of the skin paddle, but the externalized skin paddle is not limited in orientation and quantity as in the RFFF techniques. Furthermore, our monitoring paddle is positioned centrally behind the stoma, obviating later removal. We observed a 5% fistula rate and 19% stricture rate; these rates are unfortunately not reported by most other groups, but our results are comparable to those in other large series with RFFF and ALT and no monitoring segments. Notably, our observed fistula rate is lower than the 33% rate reported by Yu and colleagues before their abandonment of an externalized cutaneous monitoring paddle. Our only patient in whom a fistula did develop presented 6 weeks after operation for unknown reasons. Once recurrent disease was ruled out, he was treated with exploration and sternocleidomastoid flap closure. All patients who underwent tracheoesophageal puncture attained a functional voice. Aesthetic results were excellent because the monitoring segment became incorporated as the posterosuperior portion of the stoma (Figure 3).
In our experience, patients were considered for incorporation of this technique if the anticipated defect size and flap length could allow inclusion of the monitoring paddle without compromise of pedicle geometry or undue tension at the pharyngeal closure. As with any modification of a surgical procedure, the individual clinical situation should dictate final usage.
In conclusion, a suprastomal cutaneous monitoring paddle is a novel, reliable, and permanent method that allows direct monitoring of an otherwise buried reconstructive flap. It enables clinical observation of microvascular compromise without requiring further procedures and without any increase in morbidity or compromise of speech and swallow functions.
Corresponding Author: Michael A. Fritz, MD, Head and Neck Institute, Department of Otolaryngology–Head and Neck Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A71, Cleveland, OH 44195 (firstname.lastname@example.org).
Accepted for Publication: September 28, 2012.
Published Online: April 18, 2013. doi:10.1001/jamafacial.2013.845.
Author Contributions:Study concept and design: Revenaugh, Waters, and Fritz.
Acquisition of data: Revenaugh, Waters, Scharpf, and Knott.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: Revenaugh, Waters, and Knott.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Revenaugh.
Administrative, technical, and material support: Revenaugh, Waters, Scharpf, and Knott.
Study supervision: Scharpf, Knott, and Fritz.
Conflict of Interest Disclosures: None reported.
Additional Information: Dr Fritz is responsible for the surgical concept and implementation of the surgical technique.