RESULTS
After review of a database of over 200 scapula free tissue transfer
reconstructions conducted by the senior author (JMS) at our institution,
17 patients (13 male, 4 female) met criteria to be included in the study
(Table 1). All patients were left with total laryngopharyngectomy
defects after oncologic ablation necessitating free tissue transfer
reconstruction. Average age of the cohort at the time of surgery was
64.5 (SD 9.1, range 46.4-76.3). There were 13 Caucasian patients and the
remaining four were African American. Of all patients, 88.2% were
primary chemoradiation (n=9) or radiation-alone (n=6) failures
undergoing salvage surgery. Only two patients had not received any prior
treatment.
All patients had a preoperative diagnosis of head and neck squamous cell
carcinoma—the majority of patients had tumors involving the glottis
(n=6) and surpraglottis (n=5) with the remaining tumors being of the
oropharynx(n=2), nasopharynx (n=2), hypopharynx (n=1), or oral cavity
(n=1). Mean follow-up after surgery was 19.1 months with all patients
followed for at least 6 months.
Operative notes dictated by the primary operative surgeon (JMS) of all
reconstructions were reviewed. All patients underwent microvascular
reconstruction with a fasciocutaneous scapular free tissue transfer in a
circumferential/tubed (n=11) or non-circumferential, partially-tubed
(n=6) fashion. All patients were positioned in lateral decubitus
position for flap harvest (Figure 1), and donor sites were closed
primarily in all cases (Figure 2). Flap pedicles were based off the
subscapular or circumflex scapular artery and veins in all cases.
Recipient arteries varied based off availability of healthiest vessels
in the neck, specific defect location, and pedicle length, but the most
commonly used were the facial (n=5), superior thyroid (n=4) and
transverse cervical (n=6) arteries. In regard to veins, the external
jugular vein (n=7) or branches off the internal jugular vein (n=9) were
used in all cases. An implantable doppler was coupled to the recipient
vein in all-cases for continuous monitoring capability in the
postoperative period. Mean skin paddle size was 152.2cm2 (SD 56.2cm2,
range 67.5-242cm2) and average ischemia time was approximately 4 hours
(range 2:57-4:50). It should be noted, that the senior author prefers to
complete a majority of the hypopharyngeal reconstruction before starting
on construction of the microvascular anastomosis. This results in long
ischemia times, which would be modified by starting the microvascular
component of the case immediately after repositioning the patient.
Salivary bypass tubes were placed in the vast majority of cases at the
time of surgery (n=14). There were no significant documented
intra-operative complications.
Post-operatively, all patients were admitted to the surgical-trauma ICU
for every-1-hour nursing flap checks. Within the patient cohort, there
were no partial or total flap losses, resulting in a flap survival rate
of 100%. Donor site morbidity was also excellent, with only two
post-operative back hematoma requiring bedside drainage and placement of
a wound vac. There were no donor site wound infections or dehiscences.
Further surgical complications post-operatively included two hematomas
(one neck, one chest) and two cases of wound dehiscence (one at flap
edge, one at stoma).
Two patients developed pharyngocutaneous fistulas as inpatients
(11.7%). One fistula was closed with pectoralis flap successfully, and
the other closed after aggressive packing and the use of a wound vacuum
device. There was one major medical complication (pulmonary embolism)
and 7 minor complications including pneumonia, minor respiratory events,
arrhythmias, acute blood loss anemia, delirium, and electrolyte
disturbances (Table 2). Mean hospital length of stay was 15.7 days (SD
8.2, range 8-36 days). Adjuvant therapy (chemoradiation, chemotherapy-
or radiation-alone) was carried out in a 10 of the 17 patients
post-operatively.
Speech outcomes in the outpatient setting were reviewed (Table 3).
Pre-operatively, nutritional status was generally poor with only 7
patients able to fulfill all nutritional needs via oral intake. The
remaining patients were either supplementing with PEG feeds (n=8) or
PEG-dependent (n=2). In the postoperative setting, only one patient
remained PEG-dependent, 11 patients continued to supplement their oral
intake with PEG feeds, and 5 patients were taking solely by mouth at
last documented follow-up. Four patients required esophageal dilation in
the operating room as part of their swallowing rehabilitation. In many
cases, swallowing outcomes were affected by pre-operative swallowing
dysfunction including trismus and multi-level swallowing difficulty.
Moreover, swallowing outcomes often worsened after adjuvant treatment
with chemotherapy, radiation therapy, or both.
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, and 7 patients were utilizing an
electrolarynx with varying degrees of success.