RESULTS
After review of a database of over 200 scapula free tissue transfer reconstructions conducted by the senior author (JMS) at our institution, 17 were included in the study (Table 1). All patients were left with total laryngopharyngectomy defects after ablation necessitating free tissue transfer reconstruction. Eighty-eight percent had already undergone primary chemoradiation (n=9) or radiation-alone (n=6).
All patients had a preoperative diagnosis of squamous cell carcinoma—involving the glottis (n=6), surpraglottis (n=5), oropharynx (n=2), nasopharynx (n=2), hypopharynx (n=1), and oral cavity (n=1). Mean follow-up after surgery was 19.1 months with 6 month follow up.
Operative notes dictated by the primary operative surgeon (JMS) of all reconstructions were reviewed. All patients underwent microvascular reconstruction with a fasciocutaneous SFTT in a circumferential/tubed (n=11) or partially-tubed (n=6) fashion. All patients were positioned in lateral decubitus for harvest (Figure 1), and donor sites closed primarily (Figure 2). Flap pedicles were based off the subscapular or circumflex scapular artery and veins. Recipient arteries included facial (n=5), superior thyroid (n=4) and transverse cervical (n=6) arteries. The external jugular vein (n=7) or branches off the internal jugular vein (n=9) were used. An implantable doppler was coupled to the recipient vein for postoperative monitoring. Mean skin paddle size was 152.2cm2 (SD 56.2cm2, range 67.5-242cm2) and average ischemia time was 4 hours (range 2:57-4:50). Majority of hypopharyngeal reconstruction was completed prior to starting microvascular anastomosis. Salivary bypass tubes were placed at the time of surgery in 14 patients.
All patients were admitted to the surgical-trauma ICU for hourly flap checks. Flap survival rate was 100%. Donor site morbidity comprised two post-operative hematomas requiring drainage and wound vac placement. There was no wound infections or dehiscence. Post-surgical complications included two hematomas (one neck, one chest) and two cases of wound dehiscence (one at flap edge, one at stoma).
Two patients developed PCF as inpatients (11.7%). One fistula was closed with pectoralis flap successfully, and other with packing and use of a wound vacuum device. There was one major complication (pulmonary embolism) and 7 minor complications (Table 2). Mean hospital length of stay was 15.7 days (SD 8.2, range 8-36 days). Ten out of 17 patients received post-adjuvant therapy (chemoradiation, chemotherapy- or radiation-alone).
Speech outcomes in the outpatient setting were reviewed and are detailed in table 3. Pre-operatively, nutritional status was generally poor with only 7 patients able to fulfill nutritional needs via oral intake. In the postoperative setting, one patient remained PEG-dependent, 11 supplemented with PEG feeds, and 5 were taking solely by mouth. Four patients required esophageal dilation in the operating room. In many cases, swallowing outcomes were affected by pre-operative swallowing dysfunction including trismus and multi-level swallowing difficulty. Swallowing outcomes often worsened after adjuvant treatment.
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, 7 patients utilized an electrolarynx with varying degrees of success.