Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction

FUNCTIONAL OUTCOMES AFTER LARYNGOPHARYNGECTOMYWITH ANTEROLATERAL THIGH FLAP RECONSTRUCTION

Jan S. Lewin, PhD,1 Denise A. Barringer, MS,1 Annette H. May, MA,1 Ann M. Gillenwater, MD,1

Katherine A. Arnold, MS,1 Dianna B. Roberts, PhD,1 Peirong Yu, MD2

1 Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center,

Houston, Texas 77030. E-mail: [email protected] Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, P. O. Box 301402,

Department of Head and Neck Surgery, Unit 441, Houston, Texas 77230-1402

Accepted 24 May 2005

Published online 11 November 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20308

Abstract: Background. We examined speech and swallow-

ing outcomes and complications in patients with anterolateral

thigh (ALT) flap reconstruction of cervical esophageal defects.

Methods. We retrospectively reviewed 29 patients treated

with laryngopharyngectomy and ALT flap reconstruction at The

University of Texas M. D. Anderson Cancer Center from March

2002 to July 2004. We compared complication rates, nutritional

intake, number of tracheoesophageal punctures (TEPs), speech

fluency and use, operative defects, and radiotherapy effects.

Results. Twenty-two patients had circumferential defects,

and seven had partial defects. Twenty-four patients had radio-

therapy. Eleven patients underwent TEP. Higher complication

rates in patients after TEP compared with those without TEP were

not statistically significant (p = .268). Ninety percent of patients

with TEP spoke fluently. Ninety percent of all patients returned to

oral alimentation without significant effect from TEP (p = 1.00),

complications (p = 1.00), radiation therapy (p = 1.00), or surgical

defect (p = .56).

Conclusions. The ALT flap successfully reconstructs

laryngopharyngeal defects with excellent speech and swal-

lowing results. A 2005 Wiley Periodicals, Inc. Head Neck 28:142–149, 2006

Keywords: pharyngoesophageal defect; circumferential; anter-olateral thigh flap; jejunal flap; speech and swallowing; func-

tional outcomes

Tracheoesophageal (TE) voice production is

widely accepted as the ‘‘gold standard’’ for

alaryngeal speech restoration after a standard

total laryngectomy. TE speech offers the patient

with a laryngectomy high voice quality, ease of

speech production, and comparability to ‘‘normal’’

laryngeal speech.1,2 However, the data regarding

functional speech and swallowing outcomes are

not as clear in the controversial area of recon-

struction of the pharynx and cervical esophagus.

Reconstructive options include fasciocutaneous

flaps, myocutaneous flaps, and intestinal interpo-

sition flaps. Experience has shown that problems

are associated with mucus production, increased

vocal effort, and the ‘‘wet, cavernous’’ quality of

tracheojejunal voice in patients in whom jejunal

interposition has been used for pharyngoesopha-

geal reconstruction.3,4 Use of the radial forearm

free flap for pharyngoesophageal reconstruction

results in good speech and swallowing outcomes

Correspondence to: J. S. Lewin

B 2005 Wiley Periodicals, Inc.

HEAD & NECK February 2006142 Functional Outcomes after Laryngopharyngectomy

but with higher fistula rates and undesirable do-

nor site morbidities, especially when a large flap is

needed to reconstruct circumferential defects.5–7

Alternately, the anterolateral thigh (ALT)

flap is a pliable cutaneous segment that can be

used to repair partial defects or can be tubed to

reconstruct circumferential defects of the cervical

esophagus. The flap offers a passive conduit that

is absent of mucus, is less redundant than the

jejunal flap, and is associated with minimal donor

site morbidity even when a large flap is har-

vested. The flap can be easily used to reconstitute

the neopharyngeal conduit.8 Tracheoesophageal

puncture (TEP) can be performed primarily at the

time of reconstruction or later as a secondary

procedure for TE voice restoration. To our knowl-

edge, the work presented here is the first func-

tional outcome analysis of a series of patients who

have undergone pharyngeal reconstruction with

the ALT flap. Our purpose was to determine the

success rates of TE speech in patients with ALT

flap reconstructions and to identify critical fac-

tors that might affect postoperative TE speech

production in this patient population. We also

compared complication rates in patients with

ALT flap reconstruction and TEP with those

who did not have TEP to determine potential as-

sociations and differences between these popula-

tions. Finally, we analyzed swallowing outcomes

in patients reconstructed with an ALT flap. As

the popularity and use of the ALT flap for recon-

struction of pharyngoesophageal defects contin-

ues to grow, these data will be extremely critical

to ensure successful postoperative function.

MATERIALS AND METHODS

A retrospective analysis was performed of the

medical records of patients with advanced (T3

and T4) carcinoma of the larynx, hypopharynx,

and cervical esophagus who were treated with

laryngopharyngectomy and reconstructed with

the ALT flap between March 2002 and July

2004. Data were collected to determine the num-

ber of TEPs performed and TE speech success,

which was determined on the basis of speech

fluency and the number of patients who used TE

speech as their preferred mode of communication.

Fluent TE speech was defined as the ability to

produce a minimum of 10 to 15 words per breath

and the ability to sustain a single vowel produc-

tion for at least 10 seconds. The number of pa-

tients referred for preoperative speech pathology

consultation and the speech pathologist’s rec-

ommendation regarding puncture were analyzed

to determine the accuracy of recommendations

with ultimate TE speech success. The final means

of nutritional intake (oral vs tube) and the effects

of other factors, including the occurrence of as-

sociated complications, use of radiotherapy, and

the type of operative defect (partial vs circum-

ferential), were evaluated to determine the post-

treatment functional outcomes for both speech

and swallowing. We also evaluated potential as-

sociations with successful TE speech produc-

tion. Measurements were made before the onset

of progressive disease.

Surgical Technique. The process involved in

harvesting the ALT flap has previously been

described in detail.9 For a circumferential defect,

a flap width of 9.5 cm was obtained to give a

diameter of 3 cm for the neopharynx after tubing

the flap on itself. The distal flap-to-esophagus

anastomosis was spatulated by incising the

anterior esophageal end longitudinally for ap-

proximately 1.5 cm to minimize stricture develop-

ment. Flap insetting and closure of longitudinal

suture lines was completed using interrupted 3-0

Vicryl sutures (Ethicon Products, Cornelia, GA)

in a single layer. The fascia of the flap was used

to reinforce the suture line whenever available.

Vascular anastomoses were performed after the

flap was partially inset. The commonly used re-

cipient vessels were the transverse cervical ves-

sels. A branch of the external carotid artery and

the common facial vein trunk or internal jugular

vein was also used frequently. Postoperatively,

patients were usually kept sedated overnight in

the intensive care unit. Early mobilization was

encouraged on postoperative day 1.

Tracheoesophageal Puncture Procedure. Primary

TEPs are performed before completion of the flap

insetting. A gently curved clamp is placed in the

lumen of the esophagus and positioned against

the posterior membranous tracheal wall approx-

imately 2 cm inferior to the superior tracheal

resection margin. Then a small incision is made

in the posterior tracheal wall where it is tented

up over the clamp, and the tip of the clamp is

directed into the lumen of the trachea. A 14 or 16

French red rubber catheter tip is grasped with

the clamp and pulled into the esophageal lumen

and then directed inferiorly toward the gastro-

esophageal junction. Attention should be paid to

avoid making the opening in the common party

wall too large to avoid aspiration.

Functional Outcomes after Laryngopharyngectomy HEAD & NECK February 2006 143

If the oncologic resection requires removal of

a large part of the cervical esophagus necessi-

tating the performance of a low proximal suture

line, then it is usually prudent to delay the TEP.

Secondary TEP in patients reconstructed with

ALT flaps is performed similarly to patients

undergoing a standard laryngectomy. The cervi-

cal esophageal mucosa is directly visualized by

esophagoscopy. A large-bore needle is used to

puncture the posterior tracheal wall 2 cm inferior

to the mucocutaneous junction, and the catheter

is inserted using the Seldinger technique under

direct visualization through the esophagoscope.

Placing the TEP through the ALT flap is a little

more difficult, because the flap is usually too thick

to transilluminate. Once the optimal position is

located, a small incision is made through the skin

of the flap, then a large-bore needle can be in-

serted through this incision.

RESULTS

The population was composed of 29 patients,

23 men and six women, who underwent total

laryngopharyngectomy for advanced staged (T3

and T4) disease and were reconstructed with an

ALT flap. Three patients underwent glossectomy

in addition to laryngopharyngectomy, and five

had palsy of cranial nerve XII (CN XII). The

average age was 65 years (range, 41–82 years).

Twenty-four patients received radiation therapy,

16 as definitive therapy before undergoing surgi-

cal salvage and eight postoperatively. Twenty-two

patients had circumferential defects, and seven

had partial defects. Two of the 29 patients are

deceased. Average follow-up was 9.5 months

(range, 1–27 months). TEP was performed in 11

patients, eight primarily and three secondarily.

All primary TEPs were performed through the

remaining cervical esophagus. One of the three

secondary TEPs was performed through the

ALT flap, whereas the other two were performed

through the cervical esophagus. One patient

whose catheter became dislodged in the immedi-

ate postoperative period experienced sponta-

neous closure of his TEP and was excluded from

voice analysis.

Complications. Seven (64%) of the 11 patients

who underwent TEP, including the patient whose

catheter became dislodged postoperatively, expe-

rienced postoperative complications. A total of

eight postoperative complications occurred in pa-

tients with a TEP. Seven postoperative compli-

cations occurred in six of the eight patients who

were primarily punctured and one of the three

who was punctured secondarily. Of the eight

complications, seven occurred in the six patients

with TEP who were irradiated. Eight (44%) of

18 patients without TEP experienced postopera-

tive complications. A total of 10 postoperative

complications occurred in patients who did not

receive TEP. Of the 10 complications, nine oc-

curred in seven patients who were irradiated.

These complications, detailed in Table 1, ranged

from wound infection and fistulas to stomal ste-

nosis. There were no postoperative deaths.

Speech Pathology Consultation and Recommenda-

tions. Twenty-six patients were referred for pre-

operative consultationwith the speechpathologist.

Table 1. Postoperative findings.

Population n XRT

Complications

Other outcomes

CN XII palsy

Surgical Procedural

Fistula

Wound

infection Stricture

Stomal

stenosis*

External flap

necrosis w/

stomal stenosis

Spontaneous

loss of TEP

TEP

Primary 8 6 2 2 1 1 1 1

Secondary 3 3 1 1

Total TEP 11 9 2 2 2 1 1 2

Non-TEP 18 15 1 1 2 6 3

Total 29 24 3 1 4 8 1 1 5

Abbreviations: n, number of patients; XRT, radiotherapy; CN, cranial nerve; TEP, tracheoesophageal puncture.Note. Values represent number of patients.p = .268, overall complications for TEP vs non-TEP patients.*Considered a complication of resection, not reconstruction.


Of the 11 patients who received a TEP, 10 were re-

ferred for preoperative speech pathology consulta-

tion and recommendations, with correct prediction

of TE speech success in all 10 of these patients.

TEP was not recommended for the one patient

who failed to achieve TE speech production.

Eighteen patients did not receive TEP. TEP

was not recommended for 15 of the 16 patients

who were referred for preoperative consultation

with the speech pathologist. Primary TEP was not

recommended for five patients whose surgical

plan included extended resections (including glos-

sectomy or total esophagectomy) or for three who

had a poor medical condition (severe radiation

fibrosis, cardiopulmonary disease, or potential for

poor healing). TEP was not recommended for

seven patients who had behavioral characteris-

tics that suggested that they would be unable to

manage and take care of the prosthesis. These

included a diagnosis of dementia, history of non-

compliance with treatment recommendations,

lack of motivation, or limited family or other so-

cial support. One patient who had been recom-

mended for a primary TEP incurred injury to CN

XII during the surgical resection, and an intra-

operative decision was made not to place the TEP.

Tracheoesophageal Speech Outcomes.

Tracheoesophageal Puncture and Speech Fluency. Speech

fluency was measured in 10 patients who had a

TEP (seven primary and three secondary). Nine of

the patients, six with primary punctures and

three with secondary punctures, achieved fluent

TE speech production and used it to communi-

cate. One patient was unable to produce any

sound after TEP because of an extremely narrow

esophageal lumen and extensive postradiation

changes. Ultimately, nine patients or 90% who

received a TEP used TE voice to communicate.

Tracheoesophageal Speech and Radiation Therapy. Of the

10 patients who had a TEP, eight received radia-

tion therapy (XRT), six before surgery and two

postoperatively. Five patients who had surgical

salvage after failed primary radiation and two

with postoperative XRT became fluent TE speak-

ers and ultimately used their TEP for communi-

cation. Overall, 88% (seven of eight) of irradiated

patients with a TEP became fluent speakers and

used their TE voice for conversational purposes.

One patient who was irradiated before surgery

remained unable to speak after TEP.

Tracheoesophageal Speech Outcomes and Extent of Defect.

Eight patients who had a TEP underwent recon-

struction for circumferential defects and two for

partial defects. Seven of the eight patients with

circumferential defects and both patients with

partial defects (total 90%) became fluent speakers

and used their TE voice to communicate. Table 2

summarizes the data for TE speech outcomes.

Nutritional Intake and Diet. Overall, 26 (90%) of

29 patients were able to maintain their nutrition

by mouth. Ten (39%) of the 26 patients were able

to resume a regular oral diet inclusive of all food

consistencies, and 12 (46%) maintained a soft diet.

Four (15%) patients were only able to swallow a

pureed diet because of limitations in oral function

after surgery. Two of these patients had CNXII

palsy, one had partial resection of the base of

tongue, and the fourth patient had difficulty mas-

ticating solid foods because he was edentulous.

Three (10%) patients remained tube depen-

dent for their nutrition, two partially and one fully.

One patient who had a total glossectomy, and one

who incurred a CNXII palsy after surgery used

tube feedings to supplement oral intake. One pa-

tient was unable to take any food by mouth be-

cause of multiple postoperative problems.

No significant effect on the ability to return to

oral nutrition was identified because of the pres-

ence of a TEP (p = 1.00), occurrence of complica-

tions (p = 1.00), radiation therapy (p = 1.00), or

the extent of surgical defect (p = .56). Nutritional

outcomes for all patients are demonstrated in

Table 3.

Table 2. TE speech outcomes by timing of TEP procedure,

radiotherapy, and defect.

TEP population n Fluent Nonspeaker

Primary 7 6 (86%) 1* (14%)

+XRT 5 4 (80%) 1* (20%)

�XRT 2 2 (100%)

Secondary 3 3 (100%)

+XRT 3 3 (100%)

�XRT

Total 10 9 (90%)y 1* (10%)

Defect

Circumferential 8 7 (88%) 1* (13%)

Partial 2 2 (100%)

Abbreviations: TE, tracheoesophageal; TEP, tracheoesophageal punc-ture; XRT, radiation therapy.Note. Values represent number of patients (%).*Same patient.yAll fluent TE speakers used TE speech to communicate.


Speech Production and Effectiveness. All patients who

received a TEP achieved fluent TE speech and

were judged by certified and experienced speech

pathologists (JSL, AHM, and DAB) to have

intelligible speech production. Vocal quality was

judged acceptable and similar to the vocal quality

produced by TE speakers after simple laryngec-

tomy without reconstruction. Patients reported

similar appraisals of their speech intelligibility,

quality, and effectiveness.

Nineteen patients did not receive a TE punc-

ture. The non-TE speakers used a variety of com-

municative alternatives including the artificial

larynx (10 patients), writing (three patients),

computerized speech production (one patient),

and a combination of two or more of these com-

municative alternatives (five patients). Patients

who did not receive a TEP used their alaryngeal

speech alternatives effectively for communica-

tion purposes.

DISCUSSION

Recent reports indicate success rates as high as

97% for TE speech production in patients after

standard total laryngectomy and TEP.4 However,

TE speech production after free-flap reconstruc-

tion for laryngopharyngectomy defects has been

reported with varying rates of success.3–4,8 Our

sample size was small, but we found that 90% of

patients who received a TEP after being recon-

structed with an ALT flap after laryngopharyn-

gectomy achieved fluent TE speech production

and ultimately used TE speech for routine

communication. In fact, only one patient in this

selected group was a nonspeaker. These findings

compare favorably with TE speech outcomes for

patients with TEP after standard laryngectomy

without pharyngeal reconstruction and for pa-

tients who have been reconstructed with similar

fasciocutaneous flaps such as those from the

radial forearm. Our results showed a slightly

higher ability to return to oral alimentation after

ALT flap reconstruction (90%) compared with

that which has been reported in the literature for

patients reconstructed with a radial forearm flap

(80%). In addition, a higher rate of fistula

formation in patients with radial forearm flap

reconstruction has been reported, ranging from

17% to 67%5–7 compared with our results, which

demonstrated fistula formation in 10% of patients

reconstructed with an ALT flap.

Jejunal interposition continues to be a popu-

lar alternative for reconstruction of circumferen-

tial pharyngoesophageal defects. Several articles

have been published since the late 1980s that dis-

cuss TE speech after jejunal interposition; how-

ever, no consensus exists regarding TE speech

outcomes. TE speech proficiency ranges from ex-

cellent to poor intelligibility and fluency.10 Sim-

ilarly, little to no objective data are reported

regarding the rate of complications in this same

Table 3. Nutritional outcomes.

Variable n NPO Partially tube dependent P.O.

Diet types

Liquid Pureed Soft Regular

Complications*

With 15y 1 14 2 8 4

Without 14 2 12 2 4 6

Radiationz+XRT 24* 1 2 21 4 10 7

�XRT 5 5 2 3

Defect§

Partial 7* 7 3 4

Circum 22 1 2 19 4 9 6

TEPOTEP 10 1 9 2 7

Non-TEP 19* 2 17 4 10 3

Total 29 1 2 26 4 12 10

Abbreviations: NPO, nothing by mouth; P.O., by mouth; XRT, radiotherapy; TEP, tracheoesophageal puncture.Note. Values represent number of patients.*p = 1.00, no effect of the occurrence of complications on ability to return to oral nutrition.yOne patient was included in this group who was primarily punctured but lost his puncture before initiating oral intake.zp = 1.00, no effect of XRT on ability to return to oral nutrition.§p = .56, no effect of surgical defect on ability to return to oral nutrition.Op = 1.00, no difference between TEP and non-TEP on return to oral nutrition.


population. Only one recent investigation reports

no postoperative complications associated with

the placement of a voice prosthesis in patients

with jejunal transfer.3

Early studies regarding the occurrence of com-

plications in patients with primary versus sec-

ondary TEP have reported varying complication

rates ranging between 23% in patients with sec-

ondary TEP to 36% in patients punctured

primarily after standard total laryngectomy.

These complications have included pharyngo-

cutaneous fistulas to abscesses and bleeding.11

The most common complications continue to in-

clude loss and migration of the puncture site as a

result of dislodgment of the catheter or voice

prosthesis, formation of granulation tissue, aspi-

ration of the prosthesis, cellulitis, and stomal and

pharyngoesophageal stenosis. The problems and

complications after standard total laryngectomy

and TEP have not changed dramatically over the

years.2,11

In our sample, slightly more patients with

TEP (seven of 11, 64%) than without TEP (eight of

18, 44%) experienced complications. Most of the

complications occurred in irradiated patients who

had been punctured primarily. However, the dif-

ference was not statistically significant (p = .268;

two-tailed Fisher exact test). In both patients

with and without TEP, the rates of complications

were higher for patients who had been irradiated,

as expected. There were no life-threatening com-

plications or deaths in our small series.

Despite the increased complication rates with

radiation and primary TEP, 90% of patients in

our study who had a TEP, 78% of whom also had

radiation, became fluent speakers. Although

small samples limit the ability to draw conclu-

sions, our findings suggest that the ALT flap is a

viable phonatory source for TE speech production

that tolerates radiation without functional dete-

rioration for most patients. Larger patient sam-

ples are needed to better examine the effects of

TEP and the timing of the procedure as a primary

or secondary technique in irradiated patients

with laryngopharyngectomy and ALT flap recon-

struction. We are currently examining other fac-

tors to reduce the rate of complications in this

patient population and to facilitate faster recov-

ery and functional return.

Secondary TEP was performed in only three

patients and was done between 5 and 10 months

postoperatively after adequate healing had oc-

curred. It is, therefore, not surprising that all

three became fluent TE speakers. A significant

benefit to performing TEP as a secondary proce-

dure is the selection bias toward success. It has

been argued that delaying TEP allows sufficient

time for healing and may also help avoid the

occurrence of additional or new complications. In

addition, the delayed puncture allows the patient

time to adjust to postoperative changes in anat-

omy and physiology so that he or she can concen-

trate fully on managing the TEP for successful

TE speech production.9 However, for those pa-

tients who do receive primary TEPs, the ability

to quickly achieve TE speech production greatly

boosts their morale and facilitates postoperative

care, treatment, and rehabilitation. Despite the

higher complication rates, ultimately, patients

with TEP in this study were able to achieve

adequate healing and TE speech production.

Better control of postoperative complications will

likely expedite patient recovery and TE speech

success in a patient population whose risk for

morbidity and mortality remains high. For some

patients who physically or psychologically lack a

readiness for TE voice restoration and for others

in whom the risk for complications is great, sec-

ondary TEP may be the more conservative but

better choice for optimal success.

Only 11 of 29 patients in our series had an

attempt at TEP. Many patients with extensive

primary tumors requiring total or near-total pha-

ryngectomy are not acceptable candidates for TEP,

and preoperative assessment to determine in

which patients this should be attempted is crucial.

In addition to the medical and surgical risk

factors that are critical considerations in the

decision to perform TEP, other patient character-

istics have been shown to influence ultimate

rehabilitative success after laryngectomy. Patient

characteristics, frequently best judged by an

experienced speech pathologist, such as the pa-

tient’s cognitive functioning, ability to independ-

ently manage the prosthesis, personal hygiene

habits, emotional status, and reliability to comply

with follow-up may be equally important con-

siderations in the decision to perform a TEP and

the timing of it as a primary or secondary

procedure.3,11,12 In our series, those patients who

achieved fluent TE speech production used the

TEP to communicate before the occurrence of any

delayed complications or progressive disease.

Many patients are able to manage and care for

the TEP despite the occurrence of medical compli-

cations. For many, an immediate return to near-

normal speech production is important to their

quality of life and functional well-being. For other


patients, the responsibility of managing the TEP

becomes overwhelming. In the seven patients in

our series who were primarily punctured and

whose voice outcomes could be evaluated, six be-

came fluent speakers. In addition, primary TEP

was recommended by the speech pathologist in

these same six patients. Primary TEP was not

recommended in one patient who remained unable

to use her TE voice after the procedure. Neither

radiation treatment nor the type of defect (partial

or circumferential) prevented TE speech success.

Similar to other reports of TE speech suc-

cess after simple laryngectomy in irradiated

patients, 88% of all irradiated patients in our

study achieved fluent TE speech. Postoperative

radiation therapy often delays TE speech produc-

tion because of acute radiation sequelae that

temporarily interfere with mucosal vibration or

prevent the TE speaker from comfortably occlud-

ing the stoma to produce speech. Generally, once

the symptoms resolve, the production of TE

speech also improves.11 This seems similar for

patients reconstructed with an ALT flap. Al-

though some patients experienced temporary

difficulty occluding the stoma or poor voice pro-

duction as a result of acute edema, after this re-

solved with healing, the ALT flap provided good

vibratory results.

Swallowing outcomes were also evaluated in

our study. Ninety percent of patients in our study

were eventually able to maintain their nutrition

orally, and 88% (21 of 24) of these were irradiated.

Three (10%) remained fully or partially tube

dependent. Thus, the ALT flap seems to function

well as an alimentary conduit in most patients

after irradiation; however, larger sample sizes are

needed to confirm these findings.

It can be hypothesized that patients who have

had reconstruction of partial defects might have

better speech and swallowing function than those

who have circumferential defects because of re-

maining normal pharyngeal mucosa. Because

only two patients in this series who had partial

defects also had TEP, our results cannot prove or

disprove this theory in regard to speech. However,

our results do show high functional success with

the ALT flap. In our study, 88% (seven of eight) of

patients with TEP with circumferential defects

and partial defects achieved fluent, intelligible TE

speech and ultimately used their TE speech for

routine conversation. We can, however, comment

to the effect of partial versus circumferential

defects on swallowing ability. Nineteen of 22

patients with a circumferential defect and seven

of seven with a partial defect returned to oral

intake. Overall, 90% of the patients in this study

returned to a full oral diet with an average of

60 days from the time of surgery to removal of

the feeding tube (range, 10–330 days; median,

30 days). Thus, our findings suggest excellent

functional outcomes for patients with circumfer-

ential or partial pharyngeal defects.

CONCLUSION

The goal of reconstruction for patients with par-

tial and circumferential pharyngeal defects is to

ensure optimal, consistent, and predictable func-

tional outcomes while minimizing flap donor-site

morbidity and postoperative complications. Our

data show that the ALT flap provides an excellent

reconstructive alternative for laryngopharyngeal

defects and functional speech and swallowing

outcomes. Although our sample size was small,

our findings demonstrated that most patients be-

came fluent TE speakers and were able to return

to oral nutrition without the use of a feeding tube

despite a slightly higher rate of complications in

patients with TEP than those without TEP. Our

findings support preoperative speech pathology

referral to achieve optimal speech and swallowing

outcomes in these complicated patients. We ac-

knowledge the limited ability to draw conclusions

on the basis of small patient samples in concert

with those of retrospective analyses and plan to

perform a prospective analysis of functional out-

comes in a larger series of patients to corroborate

our findings.

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Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction