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.