Stomal recurrence after total laryngectomy is 1

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1 CASE REPORT Eben L. Rosenthal, MD, Section Editor ANTEROLATERAL THIGH FREE FLAP FOR TRACHEAL RECONSTRUCTION AFTER PARASTOMAL RECURRENCE Umberto Caliceti, MD, 1 Ottavio Piccin, MD, 1 Ottavio Cavicchi, MD, 1 Federico Contedini, MD, 2 Riccardo Cipriani, MD 2 1 ENT Department, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy. o1piccin@yahoo.it 2 Plastic Surgery Unit, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy Accepted 1 August 2008 Published online 2 February 2009 in Wiley InterScience ( DOI: /hed Abstract: Background. Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free-tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well-vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension. Methods and Results. We describe a case of a 56-year-old man with stomal recurrence after total laryngectomy treated by the use of a tubed anterolateral thigh (ALT) flap to elongate the shortened trachea and simultaneously cover the cervical skin defect. Conclusions. The ALT can be accepted as an ideal freeflap choice for stomal recurrence, because it has maximal reconstructive capacity and produces minimal donor-site morbidity. VC 2009 Wiley Periodicals, Inc. Head Neck 31: , 2009 Keywords: total laryngectomy; parastomal recurrence; free flap reconstruction; anterolateral thigh free flap; tracheal reconstruction Correspondence to: O. Piccin VC 2009 Wiley Periodicals, Inc. Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. 1,2 The highest cure rate for stomal recurrence is achieved using an aggressive radical surgical approach. Based on the location of the recurrence and the extent of involved tissue, current surgical approach may include resection of the manubrium, exploration of the mediastinum, and parastomal tracheal resection. 3 These procedures are fraught with complications, including skin slough, wound dehiscence, mediastinitis, and large vessel erosion with hemorrhage. 4 The modern techniques of soft tissue reconstruction have eliminated many of these complications. Reconstruction of a permanent tracheostoma and simultaneous resurfacing of surrounding cutaneous defects requires a significant volume of well-vascularized soft tissue. This tissue must be of appropriate thickness and pliability to facilitate its manipulation around the tracheal stump and allow suturing of tracheal remnants to skin edges without tension. A case of anterolateral thigh (ALT) perforator free flap tracheal Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK DOI /hed August

2 FIGURE 1. Preoperative image of parastomal recurrence. [Color figure can be viewed in the online issue, which is available at reconstruction after stomal recurrence resection is described. CASE REPORT FIGURE 3. Intraoperative view. [Color figure can be viewed in the online issue, which is available at com.] The patient was a 56-year-old man, who elsewhere underwent total laryngectomy and postoperative radiotherapy for squamous cell carcinoma of the glottis in The patient healed well until June 2006, when a stomal recurrence was observed. An irregular, ulcerating lesion measuring approximately 4 cm in diameter with surrounding induration was noted on the left upper tracheostoma (Figure 1). CT scan and fluorodeoxyglucose-positron emission tomography/ct (FDG-PET/CT) scan (Figure 2) excluded large vessels and esophageal involvement. The patient underwent wide resection of the peristomal recurrence, surrounding cutaneous tissue (approximately 3 cm was removed radially in an arc of 360 ), thyroid gland, and 6 tracheal rings (Figures 3 and 4). The cervical FIGURE 2. FDG-PET/CT scans show high FDG uptake (standardized uptake value 11.6) in the left side of the tracheostoma and surrounding cutaneous tissue. [Color figure can be viewed in the online issue, which is available at FIGURE 4. Resection specimen including peristomal recurrence, surrounding cutaneous tissue, thyroid gland, and 6 tracheal rings (the specimen has been split to show tumor clearance). [Color figure can be viewed in the online issue, which is available at Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK DOI /hed August 2009

3 FIGURE 5. Flap harvested, detached from donor site area, and folded to form a funnel shape. esophagus was easily dissected from the trachea. Careful blunt mediastinal dissection allowed for mobilization of the tracheal remnant. An appropriately sized ALT flap was harvested according to standard techniques to reconstruct the skin defect and to elongate the trachea to skin level First, the distal part of the flap was anastomosed to the tracheal remnant. Once the flap tracheal anastomosis was completed, the flap was tubed and shaped like a funnel (Figure 5). Successively the flap pedicle was anastomosed to the left transverse cervical artery and internal jugular vein. The proximal end of the flap was then inset to replace the cervical skin defect around the stoma (Figures 6A and 6B). After surgery, the patient was kept sedated on a ventilator overnight in a surgical intensive care unit. He was weaned off ventilator support the next day, when he was transferred to a regular ward. The postoperative course was uneventful, and the patient was decanulated 1 month after surgery. It is clear that contraction and edema resolution, in addition to suture in a tension-free manner of the transferred free tissue, have aided the patency of the stoma. Currently (22 months postoperatively), a patent stoma is maintained without requiring stomal stenting (Figure 7) and the patient is free of disease. procedure for patients who required extensive tracheal resection. 3 Unfortunately, mediastinal tracheostomy is fraught with complications, including skin slough, wound dehiscence, mediastinitis, and innominate artery erosion with subsequent vascular catastrophe. 4 The ideal reconstructive solution to these problems must provide well-vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension. Throughout the evolution of head and neck surgery, a variety of reconstructive techniques has been introduced to meet this challenge. DISCUSSION Aggresive radical surgery approach provides the best option for palliation or potential cure of a tracheostomal recurrence after laryngectomy. Prior to the introduction of free-tissue transfer, stomal recurrence after total laryngectomy represented 1 of the most challenging dilemmas for the head and neck surgeon. Mediastinal tracheostomy has been the standard reconstructive FIGURE 6. (A) Flap inset was done. (B) First the distal part of the flap was anastomosed to the tracheal remnant. Successively the proximal end of the flap was then inset to replace the cervical skin defect around the stoma. [Color figure can be viewed in the online issue, which is available at Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK DOI /hed August

4 FIGURE 7. Twenty-two months postoperatively, a patent stoma is evident without requiring stomal stenting. [Color figure can be viewed in the online issue, which is available at www. interscience.wiley.com.] Local flap coverage has been applied with limited success. Thoracoacromial, deltopectoral, and bipedicled chest flaps are useful for small defects, but have limited maneuverability with often inadequate blood supply in the random portions of the flap. The pectoralis myocutaneous flap provides a substantial amount of wellvascularized muscle and skin and has been shown to decrease the incidence of great vessel rupture. The main disadvantages of the pectoralis flap are its excessive bulk, impossibility to tube it, and significant donor site deformity and weakness. 5,6 The latissimus dorsi myocutaneous flap can also be used, but it is clearly not a first choice because of its more distant location. 7 Internal mammary artery perforator (IMAP) flap is a reliable flap that provides thin and wellvascularized tissue ideal for small tracheostoma defect reconstruction. This flap has the advantage of being less bulky than the pectoralis flap and offering aesthetic results superior to those of the deltopectoral flap. Nevertheless, IMAP flap was unable to prevent vascular accidents. 8 Free-tissue transfer provides many additional flap options and, therefore, can more specifically address the requirements of the reconstruction. The radial forearm free flap (RFFF) provides a large area of well-vascularized, pliable skin that can be easily manipulated and inset into complex defects. Cordeiro et al 9 have advocated RFFF for management of these patients. They use the free flap to resurface the skin defect and then insert the trachea into the center of the flap. This technique requires making a hole in the center of the RFFF and tacking the tracheal remnant to this hole. If the skin defect is large and the tracheal remnant is short, this approach will almost certainly result in tension on the trachea skin suture line. To obviate this problem, Wheatley et al 10 described the use of a tubed RFFF to elongate the shortened trachea eliminating tension at the trachea flap anastomosis. The entire flap is used for the tracheal reconstruction with skin deficits and then covered by local myocutaneous flaps. The use of a tubed ALT flap to elongate the shortened trachea and simultaneously cover large cervical defects, to our knowledge, has not been previously described. In our opinion, the ALT flap has several distinct advantages compared with the RFFF donor site. The ALT flap has proven its versatility by providing skin, fascia, muscle, or a combination of these for the reconstruction of simple and complex defects. The flap can be made into a thin, sensate flap, and its pedicle is long and large. The location of the donor site allows for a supine position to be maintained and a 2-team approach to be used. Unlike the RFFF, the ALT flap donor site can be closed primarily. The conical design permits a larger diameter at both proximal and distal anastomoses, and we speculate that this may contribute to a better patency rate. Finally, the skin paddle can be designed considerably larger than the RFFF. Koshima 11 originally reported a maximum dimension of 25 cm 18 cm. Recently, Yildirim et al 12 reported a maximum dimension of 20 cm 26 cm. This feature permits the reconstruction of a permanent tracheostoma and simultaneous resurfacing of surrounding cutaneous defects. The ALT flap has few disadvantages: the learning curve is undoubtedly longer than for the RFFF, mainly because the intramuscular perforator dissection is more challenging. While this does not limit the application of this donor site, the anatomical variations should be recognized. Finally, in some patients, the ALT flap may be thick, making it difficult to tube the skin paddle. Nevertheless, along with all the advantages of tracheal reconstruction by ALT flap, because of significant hair regrowth combined with non ciliated thigh epithelium, the secretion clearance may be a disadvantage when compared with a mediastinal stoma Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK DOI /hed August 2009

5 CONCLUSIONS Surgical resection provides the best opportunity for potential cure of a stomal recurrence. This case supports the use of ALT flap for tracheal reconstruction, even if a larger series will be required to determine the significance of this finding. The ALT flap represents an excellent source of tissue and is associated with less donor site morbidity compared with the RFFF donor site. In our opinion, this versatile flap should be included on the reconstructive ladder for tracheostomy reconstruction as the first choice. REFERENCES 1. Modlin B, Ogura JH. Post-laryngectomy tracheal stomal recurrences. Laryngoscope 1969;79: Weisman RA, Colman M, Ward PH. Stomal recurrence following laryngectomy: a critical evaluation. Ann Otol 1979;88: Sisson GA, Straehley CJ Jr. Mediastinal dissection for recurrent cancer after laryngectomy. Laryngoscope 1962; 73: Sisson GA, Bytell DE, Edison BD, Yeh S Jr. Transsternal radical neck dissection for control of stomal recurrences: end results. Laryngoscope 1975;85: Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63: Withers EH, Davis JL, Lynch JB. Anterior mediastinal tracheostomy with a pectoralis major musculocutaneous flap. Plast Reconstr Surg 1981;67: Shinoda M, Takagi I. Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap. Br J Plast Surg 1992;45: Yu P, Roblin P, Chevray P. Internal mammary artery perforator (IMAP) flap for tracheostoma reconstruction. Head Neck 2006;28: Cordeiro PG, Mastorakos DP, Shaha AR. The radial forearm fasciocutaneous free-tissue transfer for tracheostomy reconstruction. Plast Reconstr Surg 1996;98: Wheatley MJ, Meltzer TR, Cohen JI. Radial forearm free flap tracheal reconstruction after parastomal tumor resection. Plast Reconstr Surg 1998;101: Koshima I. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105: Yildirim S, Gideroğlu K, Aköz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction. J Reconstr Microsurg 2003;19: Anterolateral Thigh Free Flap for Tracheal Reconstruction HEAD & NECK DOI /hed August