- Email: [email protected]
The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction
+ Models
ANNPLA-1367; No. of Pages 6 Annales de chirurgie plastique esthétique (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
TECHNICAL NOTE
The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction ´ rolate ´ ral de cuisse dans les Le lambeau perforant ante reconstructions pharyngo-œsophagiennes M.K. De Frémicourt a, S. Temam b, F. Janot b, F. Kolb a, Q. Qassemyar a,* a Service de chirurgie plastique et reconstructrice, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue ´Edouard-Vaillant, 94805 Villejuif, France b ´ partement de cance ´ rologie cervicofaciale, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue De ´Edouard-Vaillant, 94805 Villejuif, France
Received 8 July 2017; accepted 11 September 2017
KEYWORDS Perforator flap; Pharyngo-esophageal reconstruction; Anterolateral thigh flap
MOTS CLÉS Lambeau perforant ; Reconstruction pharyngo-œsophagienne ; Lambeau antérolatéral de cuisse
Summary Today’s customary techniques for pharyngo-esophageal reconstruction are jejunum and radial forearm free flaps. In this type of reconstruction, the jejunum flap is considered as the reference, but when its harvesting is not possible, the radial forearm flap is used. Since perforator flaps have begun to be developed, the anterolateral thigh flap (ATF) has become increasingly prominent in pharyngo-esophageal reconstruction. The aim of our study was to describe the use of the anterolateral perforator flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks as regards oral feeding and esophageal speech. # 2017 Elsevier Masson SAS. All rights reserved. Résumé Les techniques classiques pour les reconstructions pharyngo-œsophagiennes sont les lambeaux libres de jéjunum et antébrachial radial. Le lambeau de jéjunum demeure la référence dans cette indication. Toutefois, quand il ne peut être prélevé, le lambeau antébrachial radial est alors utilisé. Depuis l’arrivée des lambeaux perforants, l’antérolatéral de cuisse ne cesse de prendre une place grandissante dans les reconstructions pharyngo-œsophagiennes. L’objectif de notre article est de présenter l’utilisation du lambeau antérolatéral de cuisse dans les reconstructions pharyngo-œsophagiennes : indications, technique de prélèvement, particularités du
* Corresponding author. E-mail address: [email protected] (Q. Qassemyar). http://dx.doi.org/10.1016/j.anplas.2017.09.004 0294-1260/# 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
+ Models
ANNPLA-1367; No. of Pages 6
2
M.K. De Frémicourt et al. design et de discuter des résultats, avantages et inconvénients en termes d’alimentation et de voix œsophagienne. # 2017 Elsevier Masson SAS. Tous droits réservés.
Introduction Different methods for pharyngo-esophageal reconstruction have been elaborated. The objectives of these techniques consist in the recovery of swallowing and phonation, with as few local and general complications as possible [1]. Pedicled flaps such as the pectoralis major and the latissimus dorsi are currently used for partial or short circular resections. For complete circular resections, free flaps predominate [2,3]. Classical techniques involve jejunum and radial forearm free flaps [4,5]. Indeed, the jejunal flap is the current reference in pharyngo-esophageal reconstruction. But when it cannot be used due to a patient’s comorbidities or previous visceral surgery, the radial forearm flap constitutes a second option. And since perforator flaps have begun to be developed, the anterolateral thigh flap (ALT) has become steadily more prominent in pharyngo-esophageal reconstruction. The objective of this article is to describe use of the ALT flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks with regard to oral feeding and esophageal speech. It could represent a supplementary solution in highly complex cases and constitute an interesting and reliable alternative approach, provided that certain principles be strictly observed.
comfort during the operation and enables the surgeon to choose the side that is simpler to harvest. The usual ALT markers are: superior lateral border of the patella, anterior superior iliac spine and a straight line connecting these two points. The paddle is centered at the middle of the line (Fig. 1). If the perforators have already been identified, the paddle can be positioned on-center or off-center. The paddle is 10 cm wide, the objective being to obtain a tube with a diameter of 3 cm. While its length is approximately 15 cm, it can be adjusted according to the specificities of the surgical specimen. The flap can be harvested whatever the thickness of the adipose panniculus (Fig. 2). The design is adjusted according to final resection. If the resection area reaches the oropharynx, a triangle with a base having the width of the paddle is added at the proximal part of the quadrilateral to model the flap as a funnel. In any case, a triangle is
Indications Candidates for circular total post-pharyngolaryngectomy (CTPL) pharyngo-esophageal reconstruction by ALT are patients for whom jejunum flaps are contraindicated or appear unsuitable. More specifically, in patients with chronic obstructive bronchopneumopathy, chronic intestinal disease, a risk of evisceration or eventration, or multiple previous digestive surgeries, reconstruction using a jejunum flap is contraindicated [6]. Similarly, the radial forearm flap is not feasible in patients with a negative Allen’s test result, with forearm scars or insufficient skin paddle. As concerns the ALT flap, patients with a scar on the thigh are excluded. Conversely, the flap thickness commonly presented in patients with sizable adipose panniculus is not a contraindication for pharyngo-esophageal reconstruction. In point of fact, during CTPL the space left available by a resection specimen allows for placement of a thick flap, through which the ‘‘empty neck’’ aspect is improved.
Figure 1 Tracing the cutaneous paddle. The two crosses represent the perforators identified by Doppler ultrasound. The letter ‘‘M’’ marks the middle of the straight line between the anterior superior iliac spine and the superior lateral border of the patella.
Flap design Perforators can be identified preoperatively by Doppler or Doppler ultrasound, which provides reliable information on their precise trajectory, their position with regard to the intermuscular septum, and length of septo-cutaneous or musculo-cutaneous trajectory. This information enhances
Figure 2 In this indication, the at-times sizable thickness of the flap is not an impediment.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
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ANNPLA-1367; No. of Pages 6
The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction
Figure 3 Design of the paddle. The esophagus will receive a posterior counter-incision so as to interpose the distal triangle and widen the anastomosis with the esophagus. If the resection area reaches the oropharynx, a triangle is added at the proximal part of the quadrilateral so as to model the flap as a funnel.
positioned in the middle of the distal portion. The esophagus receives a posterior counter-incision so as to interpose the triangle and widen the anastomosis, thereby reducing the risk of stenosis (Fig. 3).
Surgical technique Flap harvesting takes place at the same time as the CTPL. A median incision is carried out. Dissection is performed above the aponeurosis of the vastus lateralis and rectus femoris muscles. After slitting the aponeurosis, the course of the perforators is followed until it reaches the descending branch of the lateral circumflex femoral pedicle, which is dissected to its point of origin. After exeresis, required flap length is measured. As the CTPL is carried out in hyperextension, there exists a risk of harvesting an overly long flap, which would be neutrally angled. Flap length must be exactly equivalent to that of the loss of substance. Flap conformation takes place on site before pedicle sectioning. The paddle is first tubulized lengthwise, then closed by a first row of separated resorbable dermo-dermal sutures (Vicryl1 3.0). A salivary bypass tube can improve conformation, especially inasmuch as it can be left in place postoperatively and reduce contact between saliva and the sutures proximate to the flap (Fig. 4). After that, a second row is put into place at the level of underlying fat tissue by being fastened to the fascia superficialis and thereby minimizing the risk of fistula. Once conformation has been completed, the pedicle is sectioned. Salivary fistula is the major complication of pharyngo-esophageal reconstruction, with a risk of carotid artery rupture. For this reason, the longitudinal sutures are anteriorly positioned; that way, if a fistula were to appear, it would be located in front and not opposite the vessels and could be removed more easily than if it were face to the posterior wall. The cranial part of the flaps is attached by separated Vicryl1 3.0 sutures to the pre-vertebral aponeurosis, thereby providing the flap with an established fixed point and reducing weight-associated tensions at the cranial digestive anastomosis. The distal portion of the flap is anastomosed to the esophagus after posterior slitting to interpose the central triangle of the flap. Anastomosis of the
3
Figure 4 Conformation of the flap before sectioning of the pedicle on a salivary tube. Two perforators have been conserved.
arterio-venous pedicle then occurs. Given the preceding indications, we prefer the superior thyroid artery when its diameter is compatible with the flap artery; contrary to the other branches of the external carotid, it is invariably exposed and released during total pharyngolaryngectomy. As regards the receiving vein, termino-terminal anastomosis with Farabeuf’s venous trunk is performed when possible. A naso-gastric tube is put into place prior to completion of the esophageal anastomoses. Flap conformation is completed anteriorly (Fig. 5). The infrahyoid muscles are redraped in front of the flap, thereby adding a supplementary layer in front of the anastomosis with the esophagus (Fig. 6). A
Figure 5 Placement of the flap. The salivary tube is withdrawn (A) before closing of the esophageal anastomoses (B).
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
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drainage sheet is positioned at the level of the arterio-venous anastomosis and a Redon drain is placed at each side of the jugular carotid complex. The platysma myocutaneous flap adds padding laterally and at the median line, thereby securing and reinforcing the median suture (Fig. 7). At the donor site, lateral detachment can be carried out, if necessary, in order to reduce tensions. With supraaponeurosis removal, the aponeurosis is conserved and can consequently be closed. A Redon drain is placed in the
muscle compartment and a second drain astride the detached subcutaneous tissue. Wound closing is twoplaned. On D1, feeding by naso-gastric tube takes place, and the patient is allowed to move around. An upper gastro-intestinal radiography series (UGS) takes place between the tenth and the fifteenth postoperative day. If no fistula is visualized, oral feeding may begin; if a fistula is visualized, oral feeding resumption is postponed; two weeks later, a control UGS is performed. Prevention of gastro-esophageal reflux takes place postoperatively with administration of esomeprazole (40 mg/ day) and domperidone (motilium). No direct surveillance of flap vitality takes place in our department. If a patient presents with clinical signs such as fever, local inflammation or unclean secretions, naso-fibroscopy or surgical exploration may be envisioned. The esotracheal fistula permitting esophageal speech is dealt with remotely. It bears mentioning that acquisition of an esophageal voice is of higher quality with a cutaneous rather than a jejunum flap [7].
Discussion
Figure 6 Photo A shows positioning of the flap as before redraping of the infrahyoid muscles. Photo B shows the suture of the infrahyoid muscles in front of the median suture.
Figure 7 Immediate postoperative photograph. Cervical space is occupied by the flap.
The jejenum flap currently serves as the reference for postCTPL pharyngo-esophageal reconstruction. However, due to segmented vascularization maximum harvest length is 20 cm, which limits its indication in lengthy resections reaching the oropharynx or the thoracic esophagus [8]. It is contraindicated in patients suffering from chronic intestinal disease, presenting a risk of evisceration or eventration, having undergone multiple previous digestive surgeries or who are too fragile to tolerate digestive surgery. It entails risks of intestinal occlusion, ileus, eventration or evisceration and intestinal stenosis [1,9—11]. Moreover, harvesting must be centered on the pedicle, contrary to ALT, in which the paddle can be decentered from the perforators. In addition, the jejunum flap encounters serious difficulties with venous ischemia. Venous anastomosis must be carried out in front of the artery. Conformation can take place only after microsurgical anastomoses have been set up; sutures at the oropharynx and the esophagus are consequently more difficult to carry out than in ALT, during which conformation can get underway prior to creation of the vascular anastomoses. Another problematic aspect is that notwithstanding the possibility of its being extended along its mesenteriolum, the pedicle of the jejunum flap is short, an aspect rendering suturing even more difficult, and placing the pedicle at additional risk during conformation. In esophageal reconstruction, fistula formation is to be particularly feared at an early stage. Even if the superiority of ALT to jejunum flaps with regard to the latter has yet to be demonstrated, conformation of the jejunum flap seems to present greater risk [2,12]. Indeed, the intestinal lining is relatively thin, and sutures in a simple layer are more fragile than those applied in ALT. Installation of the jejunum flap requires some traction so as to avoid a ‘‘wave’’ effect; the digestive anastomosis is consequently tensed. On another score, in some cases partial glossectomy is carried out; given tissue thickness at this level, ALT seems particularly appropriate.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
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The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction Postoperative recovery time with the jejunum flap is lengthened; hospital stays average 16 days as opposed to 6.7 days for the ALT flap [13,14], with which ALT feeding by naso-gastric tube takes place as of D1, and the patient is allowed to move. From a functional standpoint, in studies comparing ALT to jejunum flaps, better swallowing and phonation are arguments in favor of ALT [1,15]. When the jejunum flap is not feasible, the radial forearm flap is the usual alternative; it is simple to harvest and reliable [16]. However, the quantity of tissue required in this type of reconstruction is considerable, and some patients, who are too small and/or undernourished, cannot provide a sufficiently large paddle. Moreover, radial forearm flaps presents more risks of fistula insofar as they contain an additional suture line at the median level, whereas jejunum flaps are only sutured at the extremities. That much said, the radial forearm flap seems to yield better results than ALT as regards voice quality, even though it entails, let us repeat, a higher risk of fistula [7]. Indeed, in ALT, deeply lying fat and fascia superficialis suture furnish a supplementary layer of stitching. The radial forearm flap leaves large scars with a risk of functional sequels, risk that is aggravated by the large amount of paddle to be harvested [17,18]. By contrast, ALT occasions no ‘‘social’’ scarring or functional risk during harvesting. From an aesthetic standpoint, jejunum and radial forearm flaps fail to sufficiently fill the cavity remaining after resectioning and leave the patient with an ‘‘empty neck’’ aspect. Given its greater thickness, ALT can cover the cervical ‘‘floor’’ and yield more acceptable aesthetic results. ALT is recognized as a reliable flap [19] in numerous and various applications [20,21]. Muscle hernias and scars are the main sequels. With the supra-aproneurosis harvesting technique, muscle aponeurosis is closed and the risk of muscle hernia, which is systematic in infra-aponeurotic harvesting, is lessened if not nullified. Flap length being 10 cm, the donor site can in most cases be closed without any need for skin graft or controlled wound healing. Patients undergoing this type of reconstruction have often lost a lot of weight and consequently possess sufficient skin laxity at the thigh, rendering the scar close to invisible. While surveillance of the flap via the patient’s clinical signs is indirect, surveillance by means of an externalized cutaneous paddle is simple to perform and easy to control, even though it all but systematically occasions fistula [14]. Due to nearby jugular and carotid vessels, Doppler control of the anastomoses is not specific. In case of doubt, nasofibroscopy monitoring can be carried out.
Conclusion As an alternative to the jejunum flap, the ALT harvesting technique running through a supra-aponeurotic vascular network in pharyngo-esophageal reconstruction seems interesting and accessible for the reconstructive surgeon. Respect in tracing, harvesting and conformation render it a cutaneoadipose flap of choice in the above-mentioned indications. Contrary to the radial forearm flap, it occupies the space in an emptied neck and is more securely sealed than median sutures, and occasions fewer morbidities. It would be interesting to make this technique better known and more widely used in pharyngo-esophageal reconstruction.
5
Disclosure of interest The authors declare that they have no competing interest.
References [1] Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg 2006;117:968—74. [2] Piazza C1, Taglietti V, Nicolai P. Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy. Curr Opin Otolaryngol Head Neck Surg 2012;20:77—88. [3] Nagel TH, Hayden RE. Advantages and limitations of free and pedicled flaps in reconstruction of pharyngoesophageal defects. Curr Opin Otolaryngol Head Neck Surg 2014;22:407—13. [4] Denewer A, Khater A, Hafez MT, Hussein O, Roshdy S, Shahatto F, et al. Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after analysis of 142 cases. World J Surg Oncol 2014;12:182. [5] López F, Obeso S, Camporro D, Fueyo A, Suárez C, Llorente JL. Outcomes following pharyngolaryngectomy with fasciocutaneous free flap reconstruction and salivary bypass tube. Laryngoscope 2013;123:591—6. [6] Parmar S, Al Asaadi Z, Martin T, Jennings C, Pracy P. The anterolateral fasciocutaneous thigh flap for circumferential pharyngeal defects˘can it really replace the jejunum? Br J Oral Maxillofac Surg 2014;52:247—50. [7] Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial forearm flap. Clin Plast Surg 1994;21:137—47. [8] Disa J, Pusic AL, Mehrara BJ. Reconstruction of the hypopharynx with the free jejunum transfer. J Surg Oncol 2006;94:466—70. [9] Coleman JJ, Tan KC, Searles JM, Hester TR, Nahai F. Jejunal free autograft: analysis of complications and their resolution. Plast Reconstr Surg 1989;84:589—95. [10] Schusterman MA, Shestak K, de Vries EJ, et al. Reconstruction of the cervical esophagus: free jejunal transfer versus gastric pull-up. Plast Reconstr Surg 1990;85:16—21. [11] Robb GL, Lewin JS, Deschler DG, et al. Speech and swallowing outcomes in reconstructions of the pharynx and cervical esophagus. Head Neck 2003;25:232—44. [12] Yu P, Hanasono MM, Skoracki RJ, Baumann DP, Lewin JS, Weber RS, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer 2010;116:1718—24. [13] Reece GP, Schusterman MA, Miller MJ, et al. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg 1995;96:1307—16. [14] Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg 2005;116:1845—55. [15] Huang TC, Hsu YC, Chen HC, Chang SC, Chen HH. Functional outcome analysis after anterolateral thigh flap reconstruction of pharyngoesophageal defect. Ann Plast Surg 2015;75:174—9. [16] Scharpf J, Esclamado RM. Reconstruction with radial forearm flaps after ablative surgery for hypopharyngeal cancer. Head Neck 2003;25:261—6. [17] Swanson E, Boyd JB, Manktelow RT. The radial forearm flap: reconstructive applications and donor site defects in 35 consecutive patients. Plast Reconstr Surg 1990;85:258—66. [18] Timmons MJ, Missotten FE, Poole MD, Davies DM. Complications of radial forearm flap donor sites. Br J Plast Surg 1986; 39:176—8.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
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[19] Tiguemounine J, Picard A, Fassio E, Goga D, Ballon G. Le lambeau antérolatéral de cuisse. Étude rétrospective. Ann Chir Plast Esthet 2005;50:62—70. [20] Coudurier J, Hitier M, Ochala C, Hamou C. Utilisation du lambeau antéro-latéral de cuisse selon la technique du chaus-
son aux pommes pour la couverture d’une large perte de substance thoracique. Ann Chir Plast Esthet 2015;60:231—4. [21] Montoya-Faivre D, Pineau V, Colson T, Brix M, Simon E. Rapport de 2 cas de couverture du genou par lambeau de face externe de cuisse en îlot rétrograde. Ann Chir Plast Esthet 2016;61:287—91.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
ANNPLA-1367; No. of Pages 6 Annales de chirurgie plastique esthétique (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
TECHNICAL NOTE
The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction ´ rolate ´ ral de cuisse dans les Le lambeau perforant ante reconstructions pharyngo-œsophagiennes M.K. De Frémicourt a, S. Temam b, F. Janot b, F. Kolb a, Q. Qassemyar a,* a Service de chirurgie plastique et reconstructrice, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue ´Edouard-Vaillant, 94805 Villejuif, France b ´ partement de cance ´ rologie cervicofaciale, Gustave-Roussy, Cancer Campus Grand Paris, 114, rue De ´Edouard-Vaillant, 94805 Villejuif, France
Received 8 July 2017; accepted 11 September 2017
KEYWORDS Perforator flap; Pharyngo-esophageal reconstruction; Anterolateral thigh flap
MOTS CLÉS Lambeau perforant ; Reconstruction pharyngo-œsophagienne ; Lambeau antérolatéral de cuisse
Summary Today’s customary techniques for pharyngo-esophageal reconstruction are jejunum and radial forearm free flaps. In this type of reconstruction, the jejunum flap is considered as the reference, but when its harvesting is not possible, the radial forearm flap is used. Since perforator flaps have begun to be developed, the anterolateral thigh flap (ATF) has become increasingly prominent in pharyngo-esophageal reconstruction. The aim of our study was to describe the use of the anterolateral perforator flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks as regards oral feeding and esophageal speech. # 2017 Elsevier Masson SAS. All rights reserved. Résumé Les techniques classiques pour les reconstructions pharyngo-œsophagiennes sont les lambeaux libres de jéjunum et antébrachial radial. Le lambeau de jéjunum demeure la référence dans cette indication. Toutefois, quand il ne peut être prélevé, le lambeau antébrachial radial est alors utilisé. Depuis l’arrivée des lambeaux perforants, l’antérolatéral de cuisse ne cesse de prendre une place grandissante dans les reconstructions pharyngo-œsophagiennes. L’objectif de notre article est de présenter l’utilisation du lambeau antérolatéral de cuisse dans les reconstructions pharyngo-œsophagiennes : indications, technique de prélèvement, particularités du
* Corresponding author. E-mail address: [email protected] (Q. Qassemyar). http://dx.doi.org/10.1016/j.anplas.2017.09.004 0294-1260/# 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
+ Models
ANNPLA-1367; No. of Pages 6
2
M.K. De Frémicourt et al. design et de discuter des résultats, avantages et inconvénients en termes d’alimentation et de voix œsophagienne. # 2017 Elsevier Masson SAS. Tous droits réservés.
Introduction Different methods for pharyngo-esophageal reconstruction have been elaborated. The objectives of these techniques consist in the recovery of swallowing and phonation, with as few local and general complications as possible [1]. Pedicled flaps such as the pectoralis major and the latissimus dorsi are currently used for partial or short circular resections. For complete circular resections, free flaps predominate [2,3]. Classical techniques involve jejunum and radial forearm free flaps [4,5]. Indeed, the jejunal flap is the current reference in pharyngo-esophageal reconstruction. But when it cannot be used due to a patient’s comorbidities or previous visceral surgery, the radial forearm flap constitutes a second option. And since perforator flaps have begun to be developed, the anterolateral thigh flap (ALT) has become steadily more prominent in pharyngo-esophageal reconstruction. The objective of this article is to describe use of the ALT flap in pharyngo-esophageal reconstruction (indications, harvesting method, flap design) and to discuss its advantages and drawbacks with regard to oral feeding and esophageal speech. It could represent a supplementary solution in highly complex cases and constitute an interesting and reliable alternative approach, provided that certain principles be strictly observed.
comfort during the operation and enables the surgeon to choose the side that is simpler to harvest. The usual ALT markers are: superior lateral border of the patella, anterior superior iliac spine and a straight line connecting these two points. The paddle is centered at the middle of the line (Fig. 1). If the perforators have already been identified, the paddle can be positioned on-center or off-center. The paddle is 10 cm wide, the objective being to obtain a tube with a diameter of 3 cm. While its length is approximately 15 cm, it can be adjusted according to the specificities of the surgical specimen. The flap can be harvested whatever the thickness of the adipose panniculus (Fig. 2). The design is adjusted according to final resection. If the resection area reaches the oropharynx, a triangle with a base having the width of the paddle is added at the proximal part of the quadrilateral to model the flap as a funnel. In any case, a triangle is
Indications Candidates for circular total post-pharyngolaryngectomy (CTPL) pharyngo-esophageal reconstruction by ALT are patients for whom jejunum flaps are contraindicated or appear unsuitable. More specifically, in patients with chronic obstructive bronchopneumopathy, chronic intestinal disease, a risk of evisceration or eventration, or multiple previous digestive surgeries, reconstruction using a jejunum flap is contraindicated [6]. Similarly, the radial forearm flap is not feasible in patients with a negative Allen’s test result, with forearm scars or insufficient skin paddle. As concerns the ALT flap, patients with a scar on the thigh are excluded. Conversely, the flap thickness commonly presented in patients with sizable adipose panniculus is not a contraindication for pharyngo-esophageal reconstruction. In point of fact, during CTPL the space left available by a resection specimen allows for placement of a thick flap, through which the ‘‘empty neck’’ aspect is improved.
Figure 1 Tracing the cutaneous paddle. The two crosses represent the perforators identified by Doppler ultrasound. The letter ‘‘M’’ marks the middle of the straight line between the anterior superior iliac spine and the superior lateral border of the patella.
Flap design Perforators can be identified preoperatively by Doppler or Doppler ultrasound, which provides reliable information on their precise trajectory, their position with regard to the intermuscular septum, and length of septo-cutaneous or musculo-cutaneous trajectory. This information enhances
Figure 2 In this indication, the at-times sizable thickness of the flap is not an impediment.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
+ Models
ANNPLA-1367; No. of Pages 6
The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction
Figure 3 Design of the paddle. The esophagus will receive a posterior counter-incision so as to interpose the distal triangle and widen the anastomosis with the esophagus. If the resection area reaches the oropharynx, a triangle is added at the proximal part of the quadrilateral so as to model the flap as a funnel.
positioned in the middle of the distal portion. The esophagus receives a posterior counter-incision so as to interpose the triangle and widen the anastomosis, thereby reducing the risk of stenosis (Fig. 3).
Surgical technique Flap harvesting takes place at the same time as the CTPL. A median incision is carried out. Dissection is performed above the aponeurosis of the vastus lateralis and rectus femoris muscles. After slitting the aponeurosis, the course of the perforators is followed until it reaches the descending branch of the lateral circumflex femoral pedicle, which is dissected to its point of origin. After exeresis, required flap length is measured. As the CTPL is carried out in hyperextension, there exists a risk of harvesting an overly long flap, which would be neutrally angled. Flap length must be exactly equivalent to that of the loss of substance. Flap conformation takes place on site before pedicle sectioning. The paddle is first tubulized lengthwise, then closed by a first row of separated resorbable dermo-dermal sutures (Vicryl1 3.0). A salivary bypass tube can improve conformation, especially inasmuch as it can be left in place postoperatively and reduce contact between saliva and the sutures proximate to the flap (Fig. 4). After that, a second row is put into place at the level of underlying fat tissue by being fastened to the fascia superficialis and thereby minimizing the risk of fistula. Once conformation has been completed, the pedicle is sectioned. Salivary fistula is the major complication of pharyngo-esophageal reconstruction, with a risk of carotid artery rupture. For this reason, the longitudinal sutures are anteriorly positioned; that way, if a fistula were to appear, it would be located in front and not opposite the vessels and could be removed more easily than if it were face to the posterior wall. The cranial part of the flaps is attached by separated Vicryl1 3.0 sutures to the pre-vertebral aponeurosis, thereby providing the flap with an established fixed point and reducing weight-associated tensions at the cranial digestive anastomosis. The distal portion of the flap is anastomosed to the esophagus after posterior slitting to interpose the central triangle of the flap. Anastomosis of the
3
Figure 4 Conformation of the flap before sectioning of the pedicle on a salivary tube. Two perforators have been conserved.
arterio-venous pedicle then occurs. Given the preceding indications, we prefer the superior thyroid artery when its diameter is compatible with the flap artery; contrary to the other branches of the external carotid, it is invariably exposed and released during total pharyngolaryngectomy. As regards the receiving vein, termino-terminal anastomosis with Farabeuf’s venous trunk is performed when possible. A naso-gastric tube is put into place prior to completion of the esophageal anastomoses. Flap conformation is completed anteriorly (Fig. 5). The infrahyoid muscles are redraped in front of the flap, thereby adding a supplementary layer in front of the anastomosis with the esophagus (Fig. 6). A
Figure 5 Placement of the flap. The salivary tube is withdrawn (A) before closing of the esophageal anastomoses (B).
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drainage sheet is positioned at the level of the arterio-venous anastomosis and a Redon drain is placed at each side of the jugular carotid complex. The platysma myocutaneous flap adds padding laterally and at the median line, thereby securing and reinforcing the median suture (Fig. 7). At the donor site, lateral detachment can be carried out, if necessary, in order to reduce tensions. With supraaponeurosis removal, the aponeurosis is conserved and can consequently be closed. A Redon drain is placed in the
muscle compartment and a second drain astride the detached subcutaneous tissue. Wound closing is twoplaned. On D1, feeding by naso-gastric tube takes place, and the patient is allowed to move around. An upper gastro-intestinal radiography series (UGS) takes place between the tenth and the fifteenth postoperative day. If no fistula is visualized, oral feeding may begin; if a fistula is visualized, oral feeding resumption is postponed; two weeks later, a control UGS is performed. Prevention of gastro-esophageal reflux takes place postoperatively with administration of esomeprazole (40 mg/ day) and domperidone (motilium). No direct surveillance of flap vitality takes place in our department. If a patient presents with clinical signs such as fever, local inflammation or unclean secretions, naso-fibroscopy or surgical exploration may be envisioned. The esotracheal fistula permitting esophageal speech is dealt with remotely. It bears mentioning that acquisition of an esophageal voice is of higher quality with a cutaneous rather than a jejunum flap [7].
Discussion
Figure 6 Photo A shows positioning of the flap as before redraping of the infrahyoid muscles. Photo B shows the suture of the infrahyoid muscles in front of the median suture.
Figure 7 Immediate postoperative photograph. Cervical space is occupied by the flap.
The jejenum flap currently serves as the reference for postCTPL pharyngo-esophageal reconstruction. However, due to segmented vascularization maximum harvest length is 20 cm, which limits its indication in lengthy resections reaching the oropharynx or the thoracic esophagus [8]. It is contraindicated in patients suffering from chronic intestinal disease, presenting a risk of evisceration or eventration, having undergone multiple previous digestive surgeries or who are too fragile to tolerate digestive surgery. It entails risks of intestinal occlusion, ileus, eventration or evisceration and intestinal stenosis [1,9—11]. Moreover, harvesting must be centered on the pedicle, contrary to ALT, in which the paddle can be decentered from the perforators. In addition, the jejunum flap encounters serious difficulties with venous ischemia. Venous anastomosis must be carried out in front of the artery. Conformation can take place only after microsurgical anastomoses have been set up; sutures at the oropharynx and the esophagus are consequently more difficult to carry out than in ALT, during which conformation can get underway prior to creation of the vascular anastomoses. Another problematic aspect is that notwithstanding the possibility of its being extended along its mesenteriolum, the pedicle of the jejunum flap is short, an aspect rendering suturing even more difficult, and placing the pedicle at additional risk during conformation. In esophageal reconstruction, fistula formation is to be particularly feared at an early stage. Even if the superiority of ALT to jejunum flaps with regard to the latter has yet to be demonstrated, conformation of the jejunum flap seems to present greater risk [2,12]. Indeed, the intestinal lining is relatively thin, and sutures in a simple layer are more fragile than those applied in ALT. Installation of the jejunum flap requires some traction so as to avoid a ‘‘wave’’ effect; the digestive anastomosis is consequently tensed. On another score, in some cases partial glossectomy is carried out; given tissue thickness at this level, ALT seems particularly appropriate.
Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004
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The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction Postoperative recovery time with the jejunum flap is lengthened; hospital stays average 16 days as opposed to 6.7 days for the ALT flap [13,14], with which ALT feeding by naso-gastric tube takes place as of D1, and the patient is allowed to move. From a functional standpoint, in studies comparing ALT to jejunum flaps, better swallowing and phonation are arguments in favor of ALT [1,15]. When the jejunum flap is not feasible, the radial forearm flap is the usual alternative; it is simple to harvest and reliable [16]. However, the quantity of tissue required in this type of reconstruction is considerable, and some patients, who are too small and/or undernourished, cannot provide a sufficiently large paddle. Moreover, radial forearm flaps presents more risks of fistula insofar as they contain an additional suture line at the median level, whereas jejunum flaps are only sutured at the extremities. That much said, the radial forearm flap seems to yield better results than ALT as regards voice quality, even though it entails, let us repeat, a higher risk of fistula [7]. Indeed, in ALT, deeply lying fat and fascia superficialis suture furnish a supplementary layer of stitching. The radial forearm flap leaves large scars with a risk of functional sequels, risk that is aggravated by the large amount of paddle to be harvested [17,18]. By contrast, ALT occasions no ‘‘social’’ scarring or functional risk during harvesting. From an aesthetic standpoint, jejunum and radial forearm flaps fail to sufficiently fill the cavity remaining after resectioning and leave the patient with an ‘‘empty neck’’ aspect. Given its greater thickness, ALT can cover the cervical ‘‘floor’’ and yield more acceptable aesthetic results. ALT is recognized as a reliable flap [19] in numerous and various applications [20,21]. Muscle hernias and scars are the main sequels. With the supra-aproneurosis harvesting technique, muscle aponeurosis is closed and the risk of muscle hernia, which is systematic in infra-aponeurotic harvesting, is lessened if not nullified. Flap length being 10 cm, the donor site can in most cases be closed without any need for skin graft or controlled wound healing. Patients undergoing this type of reconstruction have often lost a lot of weight and consequently possess sufficient skin laxity at the thigh, rendering the scar close to invisible. While surveillance of the flap via the patient’s clinical signs is indirect, surveillance by means of an externalized cutaneous paddle is simple to perform and easy to control, even though it all but systematically occasions fistula [14]. Due to nearby jugular and carotid vessels, Doppler control of the anastomoses is not specific. In case of doubt, nasofibroscopy monitoring can be carried out.
Conclusion As an alternative to the jejunum flap, the ALT harvesting technique running through a supra-aponeurotic vascular network in pharyngo-esophageal reconstruction seems interesting and accessible for the reconstructive surgeon. Respect in tracing, harvesting and conformation render it a cutaneoadipose flap of choice in the above-mentioned indications. Contrary to the radial forearm flap, it occupies the space in an emptied neck and is more securely sealed than median sutures, and occasions fewer morbidities. It would be interesting to make this technique better known and more widely used in pharyngo-esophageal reconstruction.
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Disclosure of interest The authors declare that they have no competing interest.
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Please cite this article in press as: De MK, et al. The anterolateral thigh perforator flap in pharyngo-esophageal reconstruction. Ann Chir Plast Esthet (2017), http://dx.doi.org/10.1016/j.anplas.2017.09.004