DISCUSSION
Since Dos Santos published on the anatomy of the subscapular system and introduced the scapula free flap6, much has been written on the versatility and applicability of the scapula/parascapular free flap in head and neck reconstruction. Large series have been published regarding single-institution experiences with the scapula flap. Few series focus on the fasciocutaneous iteration of the SFTT. Yoo et. al. detailed their experience with SFTT in 60 patients with only 29 of these requiring fasciocutaneous free flaps7. Of those, only one patient required hypopharyngeal reconstruction. In this review, further details of functional outcomes in this patient were not described. Another large series of 130 patients was also recently published but had only four patients requiring fasciocutaneous flaps8. Again, there was only one person with hypopharyngeal reconstruction. The fasciocutaneous SFTT was most often used in other small series for reconstruction of skin and scalp defects.
In the era of chemoradiation, the utilization of non-radiated, vascularized tissue for closure of post-laryngectomy defects has become the standard of care. Our study demonstrates that the scapular/parascapular free flap is a safe and reliable option for hypopharyngeal reconstruction. Eighty-eight percent of our patients had failed non-surgical treatment with the majority of these patients having had chemoradiation therapy (n=9). As with most patient cohorts requiring laryngectomies, nearly all patients had a significant smoking history and significant comorbidities. Of the 17 patients included, 11 patients required a complete hypopharyngeal reconstruction and the remaining 6 needed partial PE closure. Lastly, it should be noted that two patients required cervical skin reconstruction as well which was accomplished with the creation of a second flap skin paddle. Often, this determination cannot be made until the time of reconstruction making the SFTT an ideal reconstruction option due to its versatility and durability.
All scapula free tissue transfers remained viable for the duration of this review. This flap survival rate is comparable to the large retrospective series of radial forearm and anterolateral thigh free flap reconstruction post-laryngectomy9,10. Pharyngocutaneous fistulas developed in two patients in the immediate post-operative setting. These fistulas were initially managed conservatively with washout and wound packing. Closure was achieved after wound vac placement in one patient, while the other patient required a pectoralis major flap. It should be noted that the patient who required the pectoralis flap had undergone an esophagectomy for cervical esophageal cancer recurrence after previous total laryngectomy and radiation therapy. Published pharyngocutaneous fistula (PCF) rates after laryngectomy vary widely amongst authors. Recently, Yu et. al. reported a 8.8% PCF rate for PE defect reconstruction11. The majority of patients underwent free tissue reconstruction (92%) with higher rates of fistula in patients with circumferential vs. partial defects (11% vs. 6%). These figures are comparable to our PCF rate of 11.7%.
Few patients had major or minor events during the inpatient hospital stay. Despite pharmacologic venous thromboembolism prophylaxis, one patient developed bilateral deep venous thrombosis and subsequent pulmonary embolism. The patient was treated with therapeutic anticoagulation without further complications. Seven patients had minor hospital complications ranging from cardiac arrhythmias to pneumonia (Table 2). All minor complications responded to conventional treatments and did not require invasive measures. There were no immediate post-operative deaths in our patient cohort. These complications do not vary greatly from other published papers dealing with PE defect reconstruction or SFTT11,12.
Swallowing and speech outcomes were followed closely pre- and post-operatively in our cohort of patients. Speech and language pathologist(SLP) evaluations were performed independently, and these results were used as outcome measures. A majority of these evaluations were conducted via functional endoscopic evaluation of swallowing (FEES) exam. Modified barium swallow exams were conducted serially if needed. Oral intake was reestablished in 94.1% of patients with five of these patients not requiring gastrostomy tube (G tube) feeding for supplementation. Though supplementation via G tube is not ideal, several patients required supplemental nutrition due to multilevel swallowing dysfunction, debilitation due to adjuvant treatment, and cancer recurrence. Two patients who required supplemental G tube feeding suffered from debilitating trismus while having a patent neopharnyx. Only one patient could not re-establish any oral intake requiring total enteral nutrition. This patient required surgery after previous laryngectomy with stomal recurrence extending into the esophagus. Six patients were able to undergo tracheoesophageal puncture, and all of these patients had excellent voice outcomes as determined by SLP evaluation. The remaining patients are currently using electrolarynx or text/written communication at the moment. A small cohort of these patients are awaiting possible TEP placement in the future.
Donor site morbidity was minimal in our patient population. All back wounds were closed primarily after wide undermining at the time of flap harvest. In addition to placing large Jackson-Pratt drains in the surgical bed, incisional negative pressure wound therapy was employed as previously described. 13 Two patients developed back hematomas. Both were treated successfully at the bedside with partial opening of the incision and twice daily packing. Both wounds eventually healed by secondary intention. Similarly, two other patients had minor wound dehiscence along a small portion of the back closure that eventually closed secondarily. All patients participated in inpatient physical therapy after surgery with no limits on weight bearing. Lastly, no patient experienced range of motion limitations post-operatively. Other authors’ experiences with SFTT donor site morbidity have also been quite favorable12,14. Most papers cite minor wound complications and no significant muscle weakness or range-of-motion limitations even when performing osteocutaneous SFTT.
We acknowledge the pros and cons of SFTT use for hypopharyngeal closure. The ALT flap has become to gold standard in many regards for its ability to harvest large fasciocutaneous flaps capable of having multiple skin islands. Also, concurrent harvest of the ALT flap during ablative surgery much easier when compared to SFTT. Despite these advantages, they SFTT has some benefit over the ALT flap. Scapular flaps are capable of creating much large skin paddles when compared to ALT flaps without the concern for closing under extreme tension or causing a compartment syndrome. The SFTT also has much more reliable anatomy with a pristine vascular pedicle not affected by atherosclerotic changes. Moreover, since the blood supply to the skin paddle is not based on perforator dissection, the SFTT is a very robust flap often capable of being manipulated with impunity. Lastly, several institutions position the patient in partial lateral decubitus to harvest the flap concurrently with head and neck surgery. Pedicle length is usually increased in ALT flap, but since the SFTT can be oriented in various ways, this advantage is limited in the neck.
Though our outcomes using SFTT are encouraging there are some limitations to this study. Drawbacks include the retrospective nature of this review and the small sample size. Also, our study lacks a control group and our outcomes are only measured against published studies using other reconstructive options. Further studies will aim to prospectively compare outcomes between SFTT and other commonly used free flaps in PE defect reconstruction.
This study presents SFTT as a viable option for reconstruction of PE defects. Much like other microvascular free tissue transfer options, it provides adequate soft tissue coverage with a reliable, large caliber vascular pedicle. Moreover, even in circumstances where large skin paddles are required such as reconstruction of cervical skin defects, the SFTT provides abundant soft tissue with minimal donor site morbidity. Lastly, functional outcomes regarding speech and swallowing with SFTT for post-laryngectomy defects are comparable to other reconstructive options. Though this flap may not be the first option for reconstructive surgeons, it should be part of the armamentarium in complicated hypopharyngeal reconstruction.