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.