Perforator-based chimeric anterolateral thigh flap U-shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes.

BACKGROUND
Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes.


METHODS
We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires.


RESULTS
Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2.


CONCLUSIONS
The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.