Radial forearm free flap skin paddle design. The trapezoidal design allows for tubing.
Anterolateral thigh flap design. A, The skin paddle is harvested in an elliptical design. B, The skin paddle is folded to form a conical shape. C, The skin paddle is folded to form a conical shape and the closure is performed in 2 layers: the skin closure and the fascial closure.
A portion of the skin paddle can be exteriorized as a monitor.
Genden EM, Jacobson AS. The Role of the Anterolateral Thigh Flap for Pharyngoesophageal Reconstruction. Arch Otolaryngol Head Neck Surg. 2005;131(9):796-799. doi:10.1001/archotol.131.9.796
To elucidate the advantages and disadvantages of the anterolateral thigh flap (ALTF) for pharyngoesophageal reconstruction, we assessed this donor site and compared it with the radial forearm free flap (RFFF).
Retrospective medical chart review.
Tertiary care referral center.
Twenty-three consecutive patients who underwent pharyngoesophageal reconstruction using an ALTF or RFFF.
Main Outcome Measures
Patient medical charts were assessed for age, histopathological diagnosis, preoperative treatment, surgical defect, tracheoesophageal speech, flap survival, donor and recipient site complications, and swallowing function.
Twenty-three patients (12 who underwent reconstruction with ALTF and 11 with RFFF) were included in the study. Both donor sites provided adequate tissue for pharyngoesophageal reconstruction; however, the RFFF group demonstrated a higher rate of postoperative donor site complications including skin graft loss and extremity edema and stiffness. Postoperatively, the ALTF group demonstrated no gait disturbance and no donor site complications. All 23 patients in both groups were able to tolerate an unrestricted oral diet; however, 3 patients who underwent reconstruction with an RFFF experienced cervical esophageal stenosis, whereas only 1 patient with an ALTF experienced stenosis.
In this preliminary series, the ALTF represents an excellent source of tissue for pharyngoesophageal reconstruction and is associated with a lower rate of donor site morbidity and anastomotic stenosis compared with the RFFF donor site.
Prior to the introduction of free tissue transfer, pharyngoesophageal reconstruction represented one of the most challenging reconstructive dilemmas for the head and neck surgeon. Throughout the evolution of head and neck surgery, a variety of reconstructive techniques has been introduced to meet this challenge. Historically, many of the early techniques were fraught with complications including flap necrosis, wound breakdown, mediastinal infection, and great vessel erosion. Over the years, there has been a slow but steady evolution of the techniques used for the reconstruction of pharyngoesophageal defects, providing patients with an improved outcome.
In the late 1970s, microsurgical techniques were refined, and the use of free flaps was developed for the reconstruction of pharyngoesophageal defects. Initially, a variety of visceral donor sites were developed ranging from gastro-omental free flap to colonic and jejunal segments. The visceral donor sites offered thin, pliable, mucosal-lined tissue well suited for pharyngoesophageal reconstruction. In 1985 Harii et al1 introduced the radial forearm free flap (RFFF) for pharyngoesophageal reconstruction. The use of the RFFF was immediately adopted because it offered an alternative to harvesting viscera; however, the donor site morbidity and the limitation of available tissue represented limitations to this donor site.
The anterolateral thigh flap (ALTF), first described by Song et al2 in 1984, has become a popular donor site for head and neck reconstruction in Europe and Asia. More recently, the ALTF has gained popularity in the United States and is quickly becoming a key tool for microvascular reconstruction. Prior to the introduction of the ALTF, the RFFF represented the most common cutaneous donor site for pharyngoesophageal reconstruction. In an effort to reduce the donor site morbidity associated with the RFFF for pharyngoesophageal reconstruction, we applied the ALTF for reconstruction of this defect. In this study, we describe our experience with ALTF for pharyngoesophageal reconstruction and compare our results with the RFFF for the reconstruction of similar defects.
Following appropriate institutional approval, a retrospective review was performed on all patients who underwent a pharyngoesophageal reconstruction using either a RFFF or ALTF between June 1999 and February 2004. Between 1999 and 2001, patients were treated with an RFFF; however, after 2001 when the ALTF was introduced to our institution, all patients requiring a pharyngoesophageal reconstruction were treated with an ALTF. Patients were assessed for age, neoadjuvant and adjuvant treatment, histopathological diagnosis, surgical defect, flap design, flap survival, donor and recipient site complications, swallowing function, and voice rehabilitation. If alive, patients were contacted and queried regarding diet, the ability to produce an acceptable tracheoesophageal voice, and restrictions at the donor site. Patients who underwent an RFFF were asked if they experienced pain, stiffness, or a deficit in range of motion or dexterity at the donor site. Patients who underwent an ALTF were asked if they experienced pain, stiffness, or a deficit in gait or strength at the donor site.
Preoperatively, all patients had an Allen test on the nondominant forearm to ensure adequate ulnar collaterals. If an RFFF was used, a skin paddle was designed in a trapezoidal shape on the volar surface of the forearm (Figure 1). The length of the flap was measured as the length of distance between the remaining oropharyngeal mucosa and the cervical esophageal remnant. The width of the flap for circumferential defects was approximated at 10 to 12 cm at its widest dimension and 8 cm at its narrowest dimension. The flap was raised as previously described.1 In addition to the cutaneous paddle, we harvested an elliptically shaped skin paddle monitor. Following the harvest, the flap was inset and tubed prior to performing the microvascular anastomosis.
If an ALTF was used, the elliptical skin paddle was designed by drawing a line between the anterior superior iliac spine and the lateral border of the patella. The dimensions of the ellipse were determined by the length of the pharyngoesophageal defect. The width of the ellipse must not be less than the length of the pharyngoesophageal defect, and the length of the skin paddle should be 3 times the width of the flap. Once the dimensions of the flap are established, the flap is raised as previously described.3 The ALTF was harvested either as a fasciocutaneous flap or a musculocutaneous flap for cases in which a portion of muscle was desired to protect the great vessels. The elliptical skin paddle can then be folded on itself to form a conical design (Figure 2). During the inset of the flap, the distal skin paddle can be exteriorized as a monitor (Figure 3).
Twenty-three patients underwent pharyngoesophageal reconstruction at Mount Sinai Hospital, New York, NY, during a 50-month period (Table). Twelve patients underwent reconstruction with an ALTF and 11 patients with an RFFF. The age range for all patients was from 41 to 81 years (mean age, 65 years).
Of the 12 patients in the ALTF group, 10 underwent a total laryngopharyngectomy for persistent or recurrent disease following preoperative radiation (3 patients) or radiation and chemotherapy (7 patients) and 2 were treated with postoperative radiation therapy. Three patients underwent resection and reconstruction of a combined pharyngoesophageal and glossectomy defect, whereas 9 patients underwent a pharyngoesophageal reconstruction alone. Two patients underwent reconstruction with a tube design and 10 with a conical design. In 4 cases, the ALTF was harvested with a vascularized muscle flap to protect the great vessels following a modified radical neck dissection.
Of the 11 patients in the RFFF group, 8 underwent a total laryngopharyngectomy for persistent or recurrent disease following preoperative radiation and chemotherapy and 3 were treated with postoperative radiation therapy. All 11 patients underwent resection and reconstruction of a pharyngoesophageal defect using a tube design flap.
In all cases, the donor sites of the ALTFs were closed primarily, whereas all of the RFFF donor sites required a split-thickness skin graft for closure. There were no donor site complications or complaints regarding pain or disturbance of gait in the ALTF group. Four patients (36%) in the RFFF group sloughed 50% or more of the donor site skin graft. Of the 11 RFFF patients, 9 (82%) were available for follow-up, of whom 7 (78%) reported stiffness and limitation of movement in the donor site hand, whereas 8 (67%) of the 12 ALTF patients available for follow-up did not complain of a donor site deficit. In the ALTF group, there was 1 recipient site hematoma that was managed with an evacuation and 1 flap failure that was a result of a fistula and deep neck infection. In the RFFF group, there was 1 recipient site hematoma, 1 venous thrombosis that required a revision of the microvascular anastomosis, and 1 fistula that was managed conservatively. All patients from both groups were ultimately able to proceed with an unrestricted diet. One patient (8%) developed stenosis of the neopharyngoesophageal segment 18 months after surgery. In the RFFF group, 3 patients (27%) developed stenosis of the neopharyngoesophageal segment between 9 and 21 months after surgery. The stenoses presented as dysphagia in all cases, and a barium swallow was performed for confirmation in all cases. In the ALTF group, 11 patients underwent primary tracheoesophageal puncture, and 10 (90%) were able to produce a tracheoesophageal voice. Eight patients treated with an RFFF underwent a primary tracheoesophageal puncture; 6 (75%) of the 8 were able to produce a tracheoesophageal voice. Patients were assessed for their ability to voice using a tracheoesophageal voice; however, none of the patients was studied with regard to voice quality.
Reconstruction using either an enteric or cutaneous free flap can be performed in patients who undergo a total laryngopharyngectomy. Enteric flaps have several distinct advantages, including the ability to harvest the flap as a preformed tube. Unfortunately, the attendant morbidity of a laparotomy represents a limitation of this donor site. In contrast, skin-lined flaps, such as the RFFF are significantly easier to harvest and provide an excellent source of donor tissue. Over the past decade, the jejunum and RFFF flaps have become the workhorses for reconstruction of the pharyngoesophageal defect. More recently, the ALTF has become a popular donor site for head and neck reconstruction. The ALTF provides the potential for a large skin paddle with or without a vascularized muscle flap. The potential for a vascularized muscle flap in addition to the skin paddle is an advantage in cases in which the great vessels have been exposed following a resection of the sternocleidomastoid muscle. In addition, the ALTF harvest is technically straightforward. There are cases in which vascular anomalies may occur, and these have been well documented; however, the dissection can be accomplished safely once the cutaneous perforator is identified.4
In the present study, we describe our experience at Mount Sinai Hospital with 23 cases of pharyngoesophageal reconstruction using both the RFFF and ALTF to determine the advantages and disadvantages of each donor site. We found that the ALTF has several distinct advantages compared with the RFFF donor site. Unlike the RFFF, the ALTF donor site can be closed primarily. We found that the sloughing of the split-thickness skin graft, which was not uncommonly associated with the RFFF donor site, represented a high risk of donor site contractures, stiffness, and impaired dexterity. The ALTF, however, was not associated with donor site impairment. The ability to produce tracheoesophageal voice was similar in both groups; however, we found a higher rate of stenosis with the RFFF donor site compared with the ALTF. The significance of this finding is difficult to assess given the small number of patients evaluated in this series. The conical design permits a larger diameter at both proximal and distal anastomoses, and we speculate that this may contribute to a better patency rate. A larger series will be required to determine the significance of this finding. Finally, the skin paddle can be designed considerably larger than the RFFF. Koshima et al4 originally reported a maximum dimension of 25 × 18 cm. Recently, Yildirim et al5 reported a maximum dimension of 20 × 26 cm. In our experience, the large skin paddle is reliable and ideal for pharyngoesophageal reconstruction. The body habitus of the patient may, however, represent a limitation to using an ALTF. If the flap is too thick, it may preclude creation of a lumen segment.
The ALTF has few disadvantages, and some have considered it the “ideal soft tissue flap.”6 The original description of the ALTF suggested that the skin paddle was supplied by septocutaneous perforators. This led to a poor initial experience with this donor site. Subsequently, it has been determined that most ALTF skin paddles are supplied by musculocutaneous perforators. While this does not limit the application of this donor site, the anatomical variations should be recognized. In some patients, the anterolateral thigh may be thick, making it difficult to tube the skin paddle. We did not find that this was a limiting factor in our series, but it may represent a problem in an obese patient.
In conclusion, the ALTF represents an excellent source of tissue for pharyngoesophageal reconstruction and is associated with less donor site morbidity compared with the RFFF donor site.
Correspondence: Eric M. Genden, MD, Department of Otolaryngology, Box 1189, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029 (email@example.com).
Submitted for Publication: November 29, 2004; accepted April 11, 2005.
Financial Disclosure: None.
Previous Presentation: This work was presented at the Sixth International Conference on Head and Neck Cancer; August 8, 2004; Washington, DC.