Temporoparietal fascia free flap for pharyngeal coverage after salvage total laryngectomy

Authors


  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objectives/Hypothesis:

The aim of this study was to assess whether the use of the temporoparietal fascia as a free flap for pharyngeal closure reinforcement reduced the incidence of pharyngocutaneous fistula (PCF) in the salvage setting.

Study Design:

Consecutive case series.

Methods:

After research ethics board approval, 12 patients who required salvage laryngectomy, including reinforcement coverage of the primarily closed pharyngeal defect with temporoparietal fascia as a free tissue transfer, were analyzed.

Results:

One (8%) out of 12 patients experienced pharyngocutaneous fistula that responded with conservative wound packing.

Conclusions:

The PCF rate of 8% is significantly better than in similar salvage cases without flap coverage. Moreover, our PCF rate is comparable to the results shown for the pectoralis major muscle flap. The most obvious benefit of the temporoparietal fascia free flap for pharyngeal coverage in salvage laryngectomy is a reduced PCF rate with diminished donor-site morbidity, including cosmetic outcome, shoulder girdle function, and chest deformity.

INTRODUCTION

Pharyngocutaneous (PCF) fistula is a predictable complication of salvage total laryngectomy with varying reported rates of 14% to 57%.1–8 Recent reports have used regional transfer of pectoralis major myofascial flap and the use of free tissue transfer, such as the radial forearm free flap, for the purpose of providing healthy tissue to overlay the pharyngeal repair, thus mitigating the PCF incidence and its severity.7, 9, 10 The aim of the provision of nonirradiated tissue is to provide a robust overlay with as low morbidity as may be afforded to improve the nutritive healing bed in the vicinity of the pharyngeal closure line. Our intention was to incorporate vascularized coverage of the at-risk pharyngeal closure in salvage laryngectomy using a temporoparietal fascia free flap (TPFF) as an overlay technique, with no donor site complication and at least equivalent rates of PCF as seen in the literature.

MATERIALS AND METHODS

Reconstruction

All demographic and clinical data are summarized in Table I. Briefly, 12 consecutive patients who underwent salvage laryngectomy not requiring any pharyngeal resection between February 2008 and March 2011 were included in this consecutive series. More aggressive recurrences that required a pharyngeal patch, extensive soft tissue coverage, or tubed pharyngeal replacement were excluded, as they were reconstructed with alternative reconstructive methods. Our technique allowed for a two-team approach to concurrently approach the ablative component of the salvage laryngectomy with the elevation of the temporoparietal fascia flap. Preoperative color flow Doppler mapping of the vascular anatomy of the temporoparietal area was performed after induction of anesthesia. The most important Doppler signal derives from the superficial temporal vein, which can be absent (especially on the left) or follow an anomalous course in a postauricular location, divergent from the arterial pedicle. A chevron-style or hemicoronal incision was then marked with a narrow band of hair to be shaved along the incision line (Fig. 1). A facial nerve monitor (Medtronic, Brampton, Ontario, Canada) was used to monitor the frontal branch of the facial nerve while respecting the Pitanguy line. The patient was then prepared and draped in the customary fashion and received prophylactic antibiotics. The dissection proceeded in the subfollicular, supra-superficial musculoaponeurotic system plane using jeweled micro-bipolar forceps, transferring thin, pliable tissue up to the dimension 15 × 8 cm. The pedicle was traced to its emergence within the parotid gland to the level of the tragus to gain sufficient pedicle length (up to 7 cm) and to maximize the diameter of the transferred vessels for microvascular anastomosis. Following division of the pedicle, the skin was closed in layers over a flat Jackson-Pratt suction drain.

Figure 1.

Harvesting technique of the temporoparietal fascia free flap and closing of the pharyngeal defect. (a) Y incision is outlined on patient's right side. (b) Skin flaps are elevated. (c) Fascia of the temporalis muscle (asterisk) are identified. (d) Based on the superficial temporal artery and vein, the temporoparietal fascia is elevated. (e) The primary closure of the pharyngeal defect, and the arrows indicate the line of closure. (f) Temporoparietal fascia (asterisk) is used as a patch and is tucked over the closure line to support it. (g) The small arrow and the arrowhead are pointing at the arterial (inferior thyroid artery) and venous anastomosis (middle thyroid vein), respectively. (h) Closed pharyngeal defect with temporoparietal fascia (asterisk) as a patch.

Table I. Clinicopathological Data of 12 Patients Who Underwent Salvage Total Laryngectomy With Primary Closure and Pharyngeal Closure Reinforcement With a Temporoparietal Fascia Free Flap Patch
PatientSexAge, yrPrimaryTNFirst TreatmentComplicationsCorrective ProcedureFollow-Up, moOS
  1. T = tumor classification; N = nodal classification; OS = overall survival; M = male; IMRT = intensity modulated radiotherapy; N/A = not available; NED = no evidence of disease; CCRT = concomitant chemotherapy and radiotherapy; POD = postoperative day; DOD = died of disease; RT = radiotherapy; AWD = alive with disease; DOC = died of other cause, no active disease noted at time of death.

1M73Glottis30IMRT 5,000 cGy in 20 FrNoneN/A36NED
2M71Supraglottic30CCRT 6,100 cGy in 35 Fr + cisplatinPOD 11, salivary fistulaWound packing22DOD
3M45Glottis30RT 5,250 cGy in 20 FrNoneN/A17AWD
4M67Glottis20IMRT 5,000 cGy in 20 FrPartial donor site wound dehiscenceWound debridement, delayed primary closure29NED
5M80Glottis20IMRT 5,000 cGy in 20 FrNoneN/A24NED
6M76Glottis20IMRT 5,000 cGy in 20 FrNoneN/A62NED
7M72Glottis20RT 6,600 cGy in 33 FrNoneN/A8NED
8M65Glottis10IMRT 5,000 cGy in 20 FrNoneN/A16NED
9M50Glottis20RT 6,600 cGy in 33 Fr + cisplatinNoneN/A126NED
10M69Glottis20RT 6,600 cGy in 33 Fr + cisplatinNoneN/A19DOC
11M68Glottis20RT 6,600 cGy in 33 Fr + cisplatinNoneN/A71NED
12M68Supraglottic30RT 6,600 cGy in 33 Fr + cisplatinSymptomatic hypocalcemia and aspiration pneumoniaCalcium replacement, intravenous antibiotics194NED

The wide-field salvage laryngectomy with recipient vessel preparation was completed in the time taken to raise the TPFF (Fig. 1a–d,g). Once the tracheostomy was performed and the two-layer primary closure of the pharynx completed (with closure of the inferior constrictor muscle), the free flap was applied directly over the pharyngeal closure (Fig. 1e,f), tacked into position at three points, and its undersurface was sprayed with a film of tissue sealant adhesive (Fig. 1h). All veins were anastomosed using a Unilink vascular coupling device (3M Healthcare, St. Paul, MN).

The buried flaps were monitored with Doppler probes with normal arterial and venous signal for the first 7 days postoperatively. In all patients, a primary tracheoesophageal puncture was undertaken, and eventual successful voicing with a tracheoesophageal puncture prosthesis was achieved in 100% of patients. All patients were tolerating at least a dysphagia puree diet, with nine out of 12 having resumed a normal full diet by the end of follow-up.

RESULTS

Complications

Two minor complications, one wound hematoma and one partial dehiscence at the flap donor site, were noted in two patients. Conservative measures consisting of bedside procedures and diligent nursing wound care were sufficient to achieve proper wound healing without any additional operative intervention. Otherwise, no further donor site complications such as flap loss, impairment of facial nerve function, keloid, scar line, or alopecia were noted. One patient developed postoperatively episodic hypocalcemia and aspiration pneumonia.

Pharyngocutaneous Fistula

One (8%) of the 12 patients developed PCF. The patient who developed PCF was an active smoker at the time of surgery. This patient was treated with chemoradiation, consisting of 61 Gy intensity modulated radiotherapy and 3 cycles of concurrent chemotherapy that responded with conservative wound packing, and was discharged after 21 days. The average stay of those patients without fistula formation was 10 days.

DISCUSSION

Lowering the rate of PCF following salvage laryngectomy has been proposed by the recruitment of nonirradiated tissue to bolster the pharyngeal closure. This has been achieved with the use of either regional or free tissue transfer. Table II summarizes recently performed studies regarding the PCF rate in patients who underwent total salvage laryngectomy with or without soft tissue coverage. Righini et al.6 employed the pectoralis major muscle flap (PMMF) in salvage laryngectomy to cover the pharyngeal closure showing an overall PCF rate of 23%. Patel and Keni11 employed a PMMF as an overlay on the pharyngeal closure in the salvage setting and reduced the rate of PCF in a very small cohort of 10 patients to 0%. Shoulder dysfunction, difficulties with speech rehabilitation, and excessive bulk of muscle prohibiting skin closure and potentially leading to wound breakdown, as well as potential pulmonary complications including pneumonia, and decreased chest wall compliance are the most common reported complications.12–19 Regarding neck and shoulder function in particular, Moukarbel and coworkers demonstrated that the PMMF is associated with a significant impairment in neck range of motion, and loss in extension and reduced shoulder strength.20

Table II. Pharyngocutaneous Fistula Rate in Patients Undergoing Salvage Total Laryngectomy With Flap Coverage as Pharyngeal Closure Reinforcement
StudyNo. of PatientsComplication Rate, %
ALT + RFFFPMMFRFFFPrimary Closure
  1. ALT = anterolateral thigh flap; RFFF = radial forearm free flap; PMMF = pectoralis major muscle flap.

Fung 200771428   
Righini 2005660 23  
Patel 2009118 0  
Stoeckli 200055 13  
Gil 20091011 27  
Withrow 2007916  18 
Patel 2009117   57
Grau 20031472   19
Wakisaka 2008263   29
Furuta 2008351   16
Gil 20091069   27
Dirven 2009438   34

Alternatives for the pedicled PMMF is free tissue recruitment including radial forearm free flap (RFFF), anterolateral thigh flap (ALTF), and TPFF. The RFFF is characterized by a variable-sized, thin, pliable flap that can be custom sized and may be harvested as either fascia only or fasciocutaneous. Fung et al.7 described no reduction in PCF, but noted a lessening of severity of complications in those patients who had pharyngeal closure covered with a RFFF or ALT fascia only. Although a reduction in PCF rates is the sought-after outcome, a lessening of severity of PCF is perhaps at least as meaningful and has been highlighted elsewhere. The ALTF is virtually free from donor site morbidity, but is a far less suitable flap for low profile tissue coverage as is ideal in this setting. Racial differences may make the flap more favorable in Asiatic patients than in Caucasian patients.7

At our institution we prefer the TPFF for coverage of closed pharyngeal defects. There are three reasons. First, this flap is thin and pliable, with adequate size, but with limited pedicle length. The inherent thin nature and pliability brings a very robust vascular network in close proximity to the neopharyngeal suture line to promote neovascularization. This may help to explain the observed superiority over other fascial free tissue transfers (RFFF and ALTF). However, with variable surgical techniques, the use of tissue sealant adhesives, small sample size, and no head-to-head direct comparison, any conclusion is impossible. However, in-field vessel proximity mitigates the deleterious effect of the pedicle length limitations. Second, harvesting of this flap is associated with no significant donor site morbidity (Table II). Alopecia is a known effect of TPFF harvest, but our patients experienced no donor site morbidity in terms of major alopecia, or any functional or other cosmetic deficit, and no frontal branch weakness. Despite the TPFF's proximity to the ablative surgical field, we were able to undertake concurrent flap elevation and harvest when two teams were available with the flap harvest commencing once the ipsilateral selective neck dissection and laryngeal framework mobilization was complete. This provides the benefits of shorter operating time in terms of both patient welfare and caseload scheduling. Comparing operating time when performing TPFF or PMMF, it has to be suggested that there is no difference. Finally, the PCF rate in our cohort was only 8% comparable to large studies including PMMF reconstruction.7–9

CONCLUSION

The use of the temporoparietal fascial free flap as an overlay technique is a useful adjunct for salvage laryngectomy cases that do not require pharyngeal mucosal replacement. The reinforcement of the pharyngeal suture line seems to diminish the rate of pharyngocutaneous fistula compared to historical controls, with similar results to regional transfers such as the pectoralis major, with diminished donor-site morbidity, reduced length of hospitalization, and superior cosmetic outcome.

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