CASE REPORTEben L. Rosenthal, MD, Section Editor

ANTEROLATERAL THIGH FREE FLAP FOR TRACHEALRECONSTRUCTION AFTER PARASTOMAL RECURRENCE

Umberto Caliceti, MD,1 Ottavio Piccin, MD,1 Ottavio Cavicchi, MD,1 Federico Contedini, MD,2

Riccardo Cipriani, MD2

1ENT Department, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy. E-mail: o1piccin@yahoo.it2 Plastic Surgery Unit, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy

Accepted 1 August 2008Published online 2 February 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20992

Abstract: Background. Stomal recurrence after total laryn-

gectomy is 1 of the most serious issues in head and neck sur-

gery, both because of the complexity of its management and

because of its morbidity. Prior to the introduction of free-tissue

transfer, mediastinal tracheostomy has been the standard

reconstructive procedure with high rate of complications. The

ideal reconstructive solution to these problems must provide

well-vascularized soft tissues that can cover the defect after

resection and also allow suturing of the tracheal remnant to

skin edges without tension.

Methods and Results. We describe a case of a 56-year-old

man with stomal recurrence after total laryngectomy treated by

the use of a tubed anterolateral thigh (ALT) flap to elongate

the shortened trachea and simultaneously cover the cervical

skin defect.

Conclusions. The ALT can be accepted as an ideal free-

flap choice for stomal recurrence, because it has maximal

reconstructive capacity and produces minimal donor-site mor-

bidity. VVC 2009 Wiley Periodicals, Inc. Head Neck 31: 1107–

1111, 2009

Keywords: total laryngectomy; parastomal recurrence; free

flap reconstruction; anterolateral thigh free flap; tracheal

reconstruction

Stomal recurrence after total laryngectomy is 1of the most serious issues in head and neck sur-gery, both because of the complexity of its man-agement and because of its morbidity.1,2 Thehighest cure rate for stomal recurrence isachieved using an aggressive radical surgicalapproach. Based on the location of the recur-rence and the extent of involved tissue, currentsurgical approach may include resection of themanubrium, exploration of the mediastinum,and parastomal tracheal resection.3 These proce-dures are fraught with complications, includingskin slough, wound dehiscence, mediastinitis,and large vessel erosion with hemorrhage.4 Themodern techniques of soft tissue reconstructionhave eliminated many of these complications.Reconstruction of a permanent tracheostomaand simultaneous resurfacing of surroundingcutaneous defects requires a significant volumeof well-vascularized soft tissue. This tissue mustbe of appropriate thickness and pliability tofacilitate its manipulation around the trachealstump and allow suturing of tracheal remnantsto skin edges without tension. A case of antero-lateral thigh (ALT) perforator free flap tracheal

Correspondence to: O. Piccin

VVC 2009 Wiley Periodicals, Inc.

Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK—DOI 10.1002/hed August 2009 1107

reconstruction after stomal recurrence resectionis described.

CASE REPORT

The patient was a 56-year-old man, who else-where underwent total laryngectomy and postop-

erative radiotherapy for squamous cellcarcinoma of the glottis in 2005. The patienthealed well until June 2006, when a stomal re-currence was observed. An irregular, ulceratinglesion measuring approximately 4 cm in diame-ter with surrounding induration was noted onthe left upper tracheostoma (Figure 1). CT scanand fluorodeoxyglucose-positron emission tomog-raphy/CT (FDG-PET/CT) scan (Figure 2)excluded large vessels and esophageal involve-ment. The patient underwent wide resection ofthe peristomal recurrence, surrounding cutane-ous tissue (approximately 3 cm was removedradially in an arc of 360�), thyroid gland, and6 tracheal rings (Figures 3 and 4). The cervical

FIGURE 2. FDG-PET/CT scans show high FDG uptake (standar-

dized uptake value 11.6) in the left side of the tracheostoma and

surrounding cutaneous tissue. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

FIGURE 3. Intraoperative view. [Color figure can be viewed in

the online issue, which is available at www.interscience.wiley.

com.]

FIGURE 4. Resection specimen including peristomal recur-

rence, surrounding cutaneous tissue, thyroid gland, and 6 tra-

cheal rings (the specimen has been split to show tumor

clearance). [Color figure can be viewed in the online issue,

which is available at www.interscience.wiley.com.]

FIGURE 1. Preoperative image of parastomal recurrence.

[Color figure can be viewed in the online issue, which is avail-

able at www.interscience.wiley.com.]

1108 Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK—DOI 10.1002/hed August 2009

esophagus was easily dissected from the trachea.Careful blunt mediastinal dissection allowed formobilization of the tracheal remnant. An appro-priately sized ALT flap was harvested accordingto standard techniques to reconstruct the skindefect and to elongate the trachea to skin levelFirst, the distal part of the flap was anastomosedto the tracheal remnant. Once the flap–trachealanastomosis was completed, the flap was tubedand shaped like a funnel (Figure 5). Successivelythe flap pedicle was anastomosed to the lefttransverse cervical artery and internal jugularvein. The proximal end of the flap was then insetto replace the cervical skin defect around thestoma (Figures 6A and 6B). After surgery, thepatient was kept sedated on a ventilator over-night in a surgical intensive care unit. He wasweaned off ventilator support the next day, whenhe was transferred to a regular ward. The post-operative course was uneventful, and the patientwas decanulated 1 month after surgery. It isclear that contraction and edema resolution, inaddition to suture in a tension-free manner ofthe transferred free tissue, have aided the pat-ency of the stoma. Currently (22 months postop-eratively), a patent stoma is maintained withoutrequiring stomal stenting (Figure 7) and thepatient is free of disease.

DISCUSSION

Aggresive radical surgery approach provides thebest option for palliation or potential cure of atracheostomal recurrence after laryngectomy.

Prior to the introduction of free-tissue trans-fer, stomal recurrence after total laryngectomyrepresented 1 of the most challenging dilemmasfor the head and neck surgeon. Mediastinal tra-cheostomy has been the standard reconstructive

procedure for patients who required extensivetracheal resection.3 Unfortunately, mediastinaltracheostomy is fraught with complications,including skin slough, wound dehiscence, medias-tinitis, and innominate artery erosion with subse-quent vascular catastrophe.4 The idealreconstructive solution to these problems mustprovide well-vascularized soft tissues that cancover the defect after resection and also allowsuturing of the tracheal remnant to skin edgeswithout tension. Throughout the evolution ofhead and neck surgery, a variety of reconstructivetechniques has been introduced to meet thischallenge.

FIGURE 5. Flap harvested, detached from donor site area, and

folded to form a funnel shape.

FIGURE 6. (A) Flap inset was done. (B) First the distal part of

the flap was anastomosed to the tracheal remnant. Successively

the proximal end of the flap was then inset to replace the cervical

skin defect around the stoma. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK—DOI 10.1002/hed August 2009 1109

Local flap coverage has been applied withlimited success. Thoracoacromial, deltopectoral,and bipedicled chest flaps are useful for smalldefects, but have limited maneuverability withoften inadequate blood supply in the randomportions of the flap. The pectoralis myocutane-ous flap provides a substantial amount of well-vascularized muscle and skin and has beenshown to decrease the incidence of great vesselrupture. The main disadvantages of the pectora-lis flap are its excessive bulk, impossibility totube it, and significant donor site deformity andweakness.5,6 The latissimus dorsi myocutaneousflap can also be used, but it is clearly not a firstchoice because of its more distant location.7 In-ternal mammary artery perforator (IMAP) flapis a reliable flap that provides thin and well-vascularized tissue ideal for small tracheostomadefect reconstruction. This flap has the advant-age of being less bulky than the pectoralis flapand offering aesthetic results superior to thoseof the deltopectoral flap. Nevertheless, IMAPflap was unable to prevent vascular accidents.8

Free-tissue transfer provides many addi-tional flap options and, therefore, can more spe-cifically address the requirements of thereconstruction. The radial forearm free flap(RFFF) provides a large area of well-vascular-ized, pliable skin that can be easily manipulatedand inset into complex defects.

Cordeiro et al9 have advocated RFFF formanagement of these patients. They use thefree flap to resurface the skin defect and theninsert the trachea into the center of the flap.This technique requires making a hole in the

center of the RFFF and tacking the trachealremnant to this hole.

If the skin defect is large and the trachealremnant is short, this approach will almost cer-tainly result in tension on the trachea–skinsuture line.

To obviate this problem, Wheatley et al10

described the use of a tubed RFFF to elongatethe shortened trachea eliminating tension at thetrachea–flap anastomosis. The entire flap isused for the tracheal reconstruction with skindeficits and then covered by local myocutaneousflaps.

The use of a tubed ALT flap to elongate theshortened trachea and simultaneously coverlarge cervical defects, to our knowledge, has notbeen previously described.

In our opinion, the ALT flap has several dis-tinct advantages compared with the RFFF donorsite. The ALT flap has proven its versatility byproviding skin, fascia, muscle, or a combinationof these for the reconstruction of simple andcomplex defects. The flap can be made into athin, sensate flap, and its pedicle is long andlarge. The location of the donor site allows for asupine position to be maintained and a 2-teamapproach to be used.

Unlike the RFFF, the ALT flap donor sitecan be closed primarily. The conical design per-mits a larger diameter at both proximal and dis-tal anastomoses, and we speculate that this maycontribute to a better patency rate. Finally, theskin paddle can be designed considerably largerthan the RFFF. Koshima11 originally reporteda maximum dimension of 25 cm � 18 cm. Re-cently, Yildirim et al12 reported a maximumdimension of 20 cm � 26 cm. This feature per-mits the reconstruction of a permanent trache-ostoma and simultaneous resurfacing ofsurrounding cutaneous defects.

The ALT flap has few disadvantages: thelearning curve is undoubtedly longer than forthe RFFF, mainly because the intramuscularperforator dissection is more challenging. Whilethis does not limit the application of this donorsite, the anatomical variations should be recog-nized. Finally, in some patients, the ALT flapmay be thick, making it difficult to tube theskin paddle. Nevertheless, along with all theadvantages of tracheal reconstruction by ALTflap, because of significant hair regrowth com-bined with non ciliated thigh epithelium, thesecretion clearance may be a disadvantage whencompared with a mediastinal stoma.

FIGURE 7. Twenty-two months postoperatively, a patent stoma

is evident without requiring stomal stenting. [Color figure can be

viewed in the online issue, which is available at www.

interscience.wiley.com.]

1110 Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK—DOI 10.1002/hed August 2009

CONCLUSIONS

Surgical resection provides the best opportunityfor potential cure of a stomal recurrence. Thiscase supports the use of ALT flap for trachealreconstruction, even if a larger series will berequired to determine the significance of thisfinding. The ALT flap represents an excellentsource of tissue and is associated with less donorsite morbidity compared with the RFFF donorsite. In our opinion, this versatile flap should beincluded on the reconstructive ladder for trache-ostomy reconstruction as the first choice.

REFERENCES

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2. Weisman RA, Colman M, Ward PH. Stomal recurrencefollowing laryngectomy: a critical evaluation. Ann Otol1979;88:855–859.

3. Sisson GA, Straehley CJ Jr. Mediastinal dissection forrecurrent cancer after laryngectomy. Laryngoscope 1962;73:1069–1073.

4. Sisson GA, Bytell DE, Edison BD, Yeh S Jr. Transsternalradical neck dissection for control of stomal recurrences:end results. Laryngoscope 1975;85:1504–1510.

5. Ariyan S. The pectoralis major myocutaneous flap: a ver-satile flap for reconstruction in the head and neck. PlastReconstr Surg 1979;63:73–81.

6. Withers EH, Davis JL, Lynch JB. Anterior mediastinaltracheostomy with a pectoralis major musculocutaneousflap. Plast Reconstr Surg 1981;67:381–385.

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8. Yu P, Roblin P, Chevray P. Internal mammary arteryperforator (IMAP) flap for tracheostoma reconstruction.Head Neck 2006;28:723–729.

9. Cordeiro PG, Mastorakos DP, Shaha AR. The radial fore-arm fasciocutaneous free-tissue transfer for tracheos-tomy reconstruction. Plast Reconstr Surg 1996;98:354–357.

10. Wheatley MJ, Meltzer TR, Cohen JI. Radial forearm freeflap tracheal reconstruction after parastomal tumorresection. Plast Reconstr Surg 1998;101:1342–1344.

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