DISCUSSION
Dos Santos first published on the anatomy of the subscapular system and introduced the scapula free flap6. Since its original description, few series have focused on the fasciocutaneous iteration of the SFTT. Yoo et. al. detailed their experience in 60 patients with only 29 requiring fasciocutaneous free flaps7. Only one patient required hypopharyngeal reconstruction. Another series of 130 patients had only four patients requiring fasciocutaneous flaps8.
The utilization of non-radiated, vascularized tissue for closure of post-laryngectomy defects has become standard of care. 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.
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 (ALT) free flap reconstruction post-laryngectomy9,10. PCF developed in two patients in post-operative setting. Published PCF rates after laryngectomy vary widely. 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 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. One patient developed venous thromboembolism despite prophylaxis, which was treated without complication with therapeutic anticoagulation. Seven patients had minor hospital complications which responded to conventional treatments (table 2). This was comparable to other published results of PE defect reconstruction or SFTT11,12.
SLP outcomes were followed closely pre- and post-operatively in our cohort of patients. Oral intake was reestablished in 94.1% of patients with five not requiring G-tube for supplementation. Several patients required supplemental nutrition due to multilevel swallowing dysfunction, debilitation due to adjuvant treatment, and cancer recurrence. Six patients were able to undergo TEP placement, and all had excellent voice outcomes as determined by SLP evaluation. The remaining patients are currently using electrolarynx or text/written communication.
Donor site morbidity was limited as all back wounds were closed primarily at the time of flap harvest with drain placement in surgical bed and incisional negative pressure therapy as needed.13 Two patients developed back hematomas and were treated successfully at the bedside. Two other patients had minor wound dehiscence along the harvest site which healed without need for further intervention. All patients participated in inpatient physical therapy after surgery with no limits on weight bearing or range of motion. Other authors’ experiences with SFTT donor site morbidity have also been quite favorable12,14.
The ALT flap has become gold standard for free tissue transfer for its ability to harvest large fasciocutaneous flaps capable of having multiple skin islands. Also, concurrent harvest of the ALT flap during ablative surgery is more efficient compared to SFTT. On the other hand, SFTT is capable of creating large skin paddles without concern for closing under extreme tension. SFTT also has much more reliable anatomy with vascular pedicle not affected by atherosclerotic changes. The SFTT is a robust flap since blood supply to the skin paddle is not based on perforator dissection. Pedicle length is usually increased in ALT flap, but since the SFTT is versatile in terms of orientation, this advantage is limited in the neck.
Though our outcomes using SFTT are encouraging our study has a small sample size without a control group. Further studies will aim to prospectively compare outcomes between SFTT and other free flaps in PE defect reconstruction.
This study presents SFTT as a viable option for reconstruction of PE defects. It provides adequate soft tissue coverage with a reliable, large caliber vascular pedicle with minimal donor site morbidity. 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 reconstruction, it should be a consideration in complicated hypopharyngeal defects.