RESULTS
After review of a database of over 200 scapula free tissue transfer
reconstructions conducted by the senior author (JMS) at our institution,
17 were included in the study (Table 1). All patients were left with
total laryngopharyngectomy defects after ablation necessitating free
tissue transfer reconstruction. Eighty-eight percent had already
undergone primary chemoradiation (n=9) or radiation-alone (n=6).
All patients had a preoperative diagnosis of squamous cell
carcinoma—involving the glottis (n=6), surpraglottis (n=5), oropharynx
(n=2), nasopharynx (n=2), hypopharynx (n=1), and oral cavity (n=1). Mean
follow-up after surgery was 19.1 months with 6 month follow up.
Operative notes dictated by the primary operative surgeon (JMS) of all
reconstructions were reviewed. All patients underwent microvascular
reconstruction with a fasciocutaneous SFTT in a circumferential/tubed
(n=11) or partially-tubed (n=6) fashion. All patients were positioned in
lateral decubitus for harvest (Figure 1), and donor sites closed
primarily (Figure 2). Flap pedicles were based off the subscapular or
circumflex scapular artery and veins. Recipient arteries included facial
(n=5), superior thyroid (n=4) and transverse cervical (n=6) arteries.
The external jugular vein (n=7) or branches off the internal jugular
vein (n=9) were used. An implantable doppler was coupled to the
recipient vein for postoperative monitoring. Mean skin paddle size was
152.2cm2 (SD 56.2cm2, range
67.5-242cm2) and average ischemia time was 4 hours
(range 2:57-4:50). Majority of hypopharyngeal reconstruction was
completed prior to starting microvascular anastomosis. Salivary bypass
tubes were placed at the time of surgery in 14 patients.
All patients were admitted to the surgical-trauma ICU for hourly flap
checks. Flap survival rate was 100%. Donor site morbidity comprised two
post-operative hematomas requiring drainage and wound vac placement.
There was no wound infections or dehiscence. Post-surgical complications
included two hematomas (one neck, one chest) and two cases of wound
dehiscence (one at flap edge, one at stoma).
Two patients developed PCF as inpatients (11.7%). One fistula was
closed with pectoralis flap successfully, and other with packing and use
of a wound vacuum device. There was one major complication (pulmonary
embolism) and 7 minor complications (Table 2). Mean hospital length of
stay was 15.7 days (SD 8.2, range 8-36 days). Ten out of 17 patients
received post-adjuvant therapy (chemoradiation, chemotherapy- or
radiation-alone).
Speech outcomes in the outpatient setting were reviewed and are detailed
in table 3. Pre-operatively, nutritional status was generally poor with
only 7 patients able to fulfill nutritional needs via oral intake. In
the postoperative setting, one patient remained PEG-dependent, 11
supplemented with PEG feeds, and 5 were taking solely by mouth. Four
patients required esophageal dilation in the operating room. In many
cases, swallowing outcomes were affected by pre-operative swallowing
dysfunction including trismus and multi-level swallowing difficulty.
Swallowing outcomes often worsened after adjuvant treatment.
Voice outcomes varied significantly among patients in the cohort (Table
3). Four patients remained with only text/written speech for
communication, 6 patients pursued TEP placement and were progressing
with voice rehabilitation, 7 patients utilized an electrolarynx with
varying degrees of success.