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British Journal of Oral and Maxillofacial Surgery 52 (2014) 247–250
Available online at www.sciencedirect.com
he anterolateral fasciocutaneous thigh flap forircumferential pharyngeal defects—can it reallyeplace the jejunum?. Parmar a,∗, Z. Al Asaadi b, T. Martin a, C. Jennings c, P. Pracy c
Queen Elizabeth Hospital Birmingham, United KingdomDepartment of Oral & Maxillofacial Surgery, Queen Elizabeth Hospital Birmingham, United KingdomQueen Elizabeth Hospital Birmingham, Edgbaston, United Kingdom
ccepted 10 December 2013vailable online 24 January 2014
bstract
ree jejunal transfer has been used in pharyngeal reconstruction for many years, but many have criticised it as being unreliable, poorly tolerantf radiotherapy, and susceptible to stenosis and dysphagia. Recently, the trend has been to use the anterolateral thigh (ALT) flap to overcomehese problems, and many authors have reported good results. At the University of Birmingham we used the jejunal free flap for pharyngealeconstruction for many years, but in view of recent reports we changed to the ALT flap. We retrospectively analysed all patients who hadharyngeal reconstruction with an ALT flap in our unit since changing from the jejunal flap. Only circumferential defects were included.ix patients had pharyngeal resection and required reconstruction of a circumferential defect between 2007 and 2010. All the defects wereeconstructed with a tubed ALT flap. No flaps failed and there was no partial necrosis. However, stricturing still occurred and the diet of many
atients was restricted. Three patients required the flap to be replaced with a jejunal free flap. Although no flaps failed, we have not been ableo replicate the results of other surgeons and have therefore abandoned use of the ALT flap and returned to use of the jejunal free flap for theeconstruction of circumferential pharyngeal defects.2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Ro
eto1fi
eywords: Pharyngeal reconstruction; ALT flap; Pharyngeal carcinoma
ntroduction
haryngeal reconstruction is a challenging and demandingrocedure. Patients often have a poor prognosis, and theres a serious risk of postoperative complications, and poten-ial functional problems with speech and swallowing.1 Aarge proportion of operations are done as salvage on patientsho have already had chemotherapy and radiotherapy.2 Free
ejunal transfer has been used for many years, but reconstruc-ion has been criticised as being unreliable, poorly tolerantf radiotherapy, and susceptible to stenosis and dysphagia.3
∗ Corresponding author at: Queen Elizabeth Hospital Birmingham, Edg-aston B15 2TH, United Kingdom. Tel.: +44 7876762095;ax: +44 0121 371 5027.
E-mail address: [email protected] (S. Parmar).
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266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofaciahttp://dx.doi.org/10.1016/j.bjoms.2013.12.008
ecently, the anterolateral thigh (ALT) flap has been used tovercome these problems.1,2,4
The University Hospital, Birmingham, has over 20 years’xperience of the jejunal flap for pharyngeal reconstruc-ion in 168 patients (awaiting publication). On reviewingur outcomes we noted that 97% of flaps were successful,0% of patients had donor site complications, and 11% hadstulas. Although a proportion of patients were lost to long-
erm follow-up, normal oral intake was achieved in 90%nd only 9% required a long-term feeding adjunct. Func-ional speech was achieved in 80% of patients one yearostoperatively.
However, because of the reports of successful outcomes
or pharyngeal reconstruction using the ALT flap and its suc-essful use in our unit in other head and neck defects, weecided to use the ALT instead of the jejunal flap. The aiml Surgeons. Published by Elsevier Ltd. All rights reserved.
2 l and Maxillofacial Surgery 52 (2014) 247–250
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Rep
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No
Nor
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Chr
onic
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48 S. Parmar et al. / British Journal of Ora
f this series was to review outcomes of pharyngeal recon-truction with the ALT flap.
aterials and methods
e began using ALT flaps for pharyngeal reconstructionn 2007. We retrospectively reviewed all patients who hadad reconstruction of circumferential defects with an ALTree flap in the University Hospital, Birmingham, between007 and 2010. We reviewed the data from medical recordsn patients’ characteristics, details of operation, immediateostoperative complications, adjuvant treatment, failure orecrosis of the flap, development of fistulas and strictures,olerance of oral intake, and rehabilitation of speech. Func-ional outcomes were assessed by the speech and languageherapy team.
urgical technique
he ALT flap was raised as a perforator flap using a standardechnique previously described by Yu et al. for pharyn-eal reconstruction.2,3,5 It was based on a combination ofeptocutaneous and musculocutaneous perforators from theescending branch of the lateral femoral circumflex artery. Aistal V-shaped extension of flap tissue was included and spat-lated to the anterior oesophagus, which has been reported torevent the late stricturing.1,5 The flap was harvested with aascial cuff beyond the skin incision for layered closure. Theonor site was always closed primarily.
The flap was tubed around a salivary bypass tube using triple closure technique (skin, subcutaneous tissue, thenascia) and a combination of resorbable and non-resorbableutures was used. It was then set into the pharyngeal defectnd the upper and lower anastomoses were done. Arterialnastomosis was to the facial artery (end-to-end) and venousnastomosis to the internal jugular vein (end-to-side). Thealivary bypass tube was left in place for 2 weeks and oralntake resumed once it had been removed.
esults
ix patients (5 male and one female, mean age 68.7 years,ange 53–80) had pharyngeal resection and required recon-truction with an ALT flap. Five had primary operation; onead had laryngeal carcinoma 20 years previously. Four of the
patients had adjuvant radiotherapy. All 6 patients had tubedeconstructions with the temporary use of a salivary bypassube. Patients’ details are shown in Table 1.
No flaps failed and there was no necrosis. One patienteveloped a wound infection at the donor site and had a split
kin graft. Three patients had fistulas, 2 of which were per-istent. Stricturing of the flap occurred in 4 and all of themeeded repeated dilatation. Three patients were able to takesemi-solid diet, and oral intake was not possible in 2. Tabl
e
1Pa
tient
s’
de
Cas
e
No.
1 2 3 4 5 6 SCC
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S. Parmar et al. / British Journal of Oral
With respect to speech rehabilitation, surgical voiceestoration was attempted in 5 patients (one patient declined);
achieved functional trans-oesophageal speech. The other 3atients had complications. Two had difficulty occluding thetoma and in one the valve became dislodged repeatedly andventually the trans-oesophageal puncture closed.
In 3 patients the ALT flap was replaced with a jejunal flap; fourth was offered this option but declined. Replacementsere indicated because of stricturing in 2, and a persistentstula in the third.
iscussion
he gold standard for pharyngeal reconstruction would be reliable, single stage procedure that would result in goodwallowing, low rates of stricture, good rehabilitation ofpeech, and low donor site morbidity. It would also be suitableor circumferential as well as partial defects.
ejunal flaps
istorically, local flaps, pectoralis major, deltopectoral flaps,nd gastric pull-ups were used for pharyngeal reconstruction,ut with the development of miscrosurgical techniques, freeaps have been adopted as the technique of choice.6 Entericree flaps, including the jejunal flap, were originally favoured,nd the indications for a jejunal flap include circumferentialnd near-circumferential defects. Because of the segmentallood supply, up to 20 cm of jejunum can be harvested, whichenerally limits its use to the cervical oesophagus.7 Jejunalaps are contraindicated in patients with chronic intestinalisease, liver disease, and in those who have had multiplerevious abdominal procedures, but advantages include itsubular structure and relatively low fistula rates. In a study of0 flaps by Disa et al., there was a 10% fistula rate postopera-ively and most healed spontaneously.8 Some of the potentialroblems and complications include donor site morbidity,leus, small bowel obstruction, ventral hernia, and stricture.3
nterolateral thigh (ALT) flaps
he original fasciocutaneous flap was the radial forearm flap,rst used by Harii et al. in 1985.9 Since then the ALT flapas become a popular choice for pharyngeal defects. Manyf its proponents point to its versatility in terms of size, lowonor site morbidity and complications (particularly whenompared with the potential complications associated withhe jejunal flap during and after operation), and the fact that
teams can operate at the same time.6,10
Several studies point to low rates of fistula andtricture,2,5,6,10 and some good results have been reported in
arger studies on the reconstruction of pharyngeal defects.n the largest study we know of, Yu et al. reviewed 114atients who had pharyngoesophageal reconstruction withn ALT flap, 67 of whom had circumferential defects.2ism
axillofacial Surgery 52 (2014) 247–250 249
verall, 95% of flaps were successful, fistulas occurred in0% of patients, and 7 (6%) had strictures. Ninety-one per-ent of patients could tolerate an oral diet and 30% achievedracheo-oesophageal speech.
In a review of 55 patients by Spyroupoulou et al., 92.7%f ALT flaps were successful and fistula and stricture ratesere 18.1% and 5.4%, respectively.4 Ho et al. reported a
eries of 15 patients with a fistula rate of 6.6%, but a thirdf all patients had stricturing. Speech was rehabilitated in 4atients (27%).1
All these studies included a mix of partial and circumfer-ntial pharyngeal defects.
Many proponents of the ALT flap suggest that the ratesor fistula and stricture are lower than those for other flaps,ut a number of studies as well as our own series report aigh fistula rate and long-term problems with swallowing,articularly after reconstruction of circumferential defects.
A review by Murray et al. of 67 ALT flaps from 3 stud-es showed an average fistula rate of 16.4% and stricturingn 11.9% of patients. However, 18% of those with circum-erential defects had strictures compared with 5% of thoseith partial defects. Rates for fistulas were about the same
or circumferential and partial defects.6
Of the 55 cases in the study by Spyroupoulou et al., 24ad circumferential defects and stricture and fistula rates were2.5% and 25%, respectively.4 Ho et al. also reported a higherate of stricturing in circumferential defects than in partialefects, rising from a third to 40%.1 In their review of 114aps, Yu et al. reported 7 patients with strictures (6%),2 6 ofhom had circumferential defects.Radiotherapy before or after operation seems to affect suc-
ess. In some studies many of the patients who had operationsor recurrence had previously had operation or radiotherapy,r both. Yu et al. found that 48% of patients had previ-usly had operation and radiotherapy, and 19% had hadadiotherapy alone.2 Higher fistula rates were seen in thoseho had had preoperative radiotherapy which is consistentith the difficulty of operating in a previously irradiatedeld. Stricturing seemed more common in patients who hadad postoperative radiotherapy. Five of our 6 patients hadperation and postoperative radiotherapy as their primaryreatment, and one had previously had laryngeal carcinoma,hich had been treated with radiotherapy. The high rate of
trictures in our series is consistent with those reported inther studies for patients who had had postoperative radio-herapy.
Three of our 6 patients had to have their ALT flap replacedith a jejunal flap. We chose jejunal reconstruction becausef our previous success with this flap. All were successfulnd there were no fistulas or stricturing, but it must be notedhat as they were placed some time after radiotherapy hadeen completed, they were not subjected to irradiation.
Difficulties with the rehabilitation of speech and oralntake in our patients could partly be caused by steno-is, which affected those with strictures. Only one patientanaged a normal oral intake after treatment, which is
2 l and M
pfl
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otagm
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50 S. Parmar et al. / British Journal of Ora
oor when it was possible in 90% of those with jejunalaps.
This series is limited by the small number of cases, andutcomes might have been better if more had been included.lthough some of the larger series report initial problemsith flaps,5 outcomes were improved when they had mod-
fied their surgical technique. We replicated the modifiedechnique, but because of our superior results with the jeju-al flap and because of the higher fistula and stricture rateseported for circumferential defects, we abandoned use of theLT flap and have subsequently used the jejunal free flap to
econstruct circumferential pharyngeal defects.All reconstructive surgery should be tailored to the needs
f individual patients and should take into account their his-ory, prognosis, and the potential complications. Immediatend long-term complications must be considered for pharyn-eal reconstruction, and management must ensure minimalorbidity and a good quality of life.
eferences
1. Ho MW, Houghton L, Gillmartin E, et al. Outcomes following pharyn-golaryngectomy reconstruction with the anterolateral thigh (ALT) freeflap. Br J Oral Maxillofac Surg 2012;50:19–24.
1
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2. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruc-tion with the anterolateral thigh flap after total laryngopharyngectomy.Cancer 2010;116:1718–24.
3. Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical andfunctional outcomes and hospital costs following pharyngoesophagealreconstruction with the anterolateral thigh free flap versus the jejunalflap. Plast Reconstr Surg 2006;117:968–74.
4. Spyropoulou GA, Lin PY, Chien CY, Kuo YR, Jeng SF. Reconstructionof the hypopharynx with the anterolateral thigh flap: defect classifi-cation, method, tips, and outcomes. Plast Reconstr Surg 2011;127:161–72.
5. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateralthigh flap: a clinical and functional outcomes study. Plast Reconstr Surg2005;116:1845–55.
6. Murray DJ, Novak C, Neligan PC. Fasciocutaneous free flaps inpharyngolaryngo-oesophageal reconstruction: a critical review of theliterature. J Plast Reconstr Aesthet Surg 2008;61:1148–56.
7. Disa J, Pusic AL, Mehrara BJ. Reconstruction of the hypopharynx withthe free jejunum transfer. J Surg Oncol 2006;94:466–70.
8. Disa JJ, Pusic AL, Hidalgo DA, Cordeiro PG. Microvascular reconstruc-tion of the hypopharynx: defect classification, treatment algorithm, andfunctional outcome based on 165 consecutive cases. Plast Reconstr Surg2003;111:652–60.
9. Harii K, Ebihara S, Ono I, Saito H, Terui S, Takato T. Pharyngoesophagealreconstruction using a fabricated forearm free flap. Plast Reconstr Surg
1985;75:463–76.0. Genden EM, Jacobson AS. The role of the anterolateral thigh flap forpharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg2005;131:796–9.
