A Simple Technical Modification for the Creation of an External Monitoring Skin Paddle for Tubed ALT Flap Reconstruction after Circumferential Hypopharyngeal Resection.

Supplemental Digital Content is available in the text.

Total laryngopharyngectomy remains the mainstay of treatment for advanced or residual postradiotherapy hypopharyngeal cancer. The tubed anterolateral thigh (ALT) flap is a popular reconstructive option for this complex defect.[1] Postoperative monitoring of this buried flap, however, is clinically challenging.

Various flap externalization methods have been reported, including the use of chimeric design of the ALT flap based on a second perforator,[2] the use of deepithelialized portion of the flap,[3] the use of the distal stump of the ALT flap pedicle,[4] and the use of a small segment of vastus lateralis muscle.[5] However, the chimeric design may not always be possible because of the variation of the perforator numbers and locations of ALT flap, the deepithelialized ALT flap may be hard to be folded and externalized because of its bulkiness that may increase the chance of fistula,[1] the exposed distal pedicle stump may not be reliable for monitoring the venous condition, and the small muscle segment from the vastus lateralis muscle may dry out when it is exposed externally.

Here, we present a simple technical modification to the tubed ALT flap that permanently externalizes a distal skin paddle of the buried tube flap, allowing for direct flap monitoring. The skin paddle for tubularization was extended distally into a fusiform shape with the distal part prepared for externalization (see figure, Supplemental Digital Content 1, which displays that the skin paddle for tubularization was extended distally into a fusiform shape with the distal part prepared for externalization, http://links.lww.com/PRSGO/A454). The distal skin paddle was cut through the dermis with the subcutaneous tissue and fascia attached to the main flap. It remained well perfused while waiting for the tumor ablation surgery (Fig. 1). The flap pedicle was divided, and the main flap was tubularized to serve as neohypopharynx (see figure, Supplemental Digital Content 2, which displays that the flap pedicle was divided and the main flap was tubularized to serve as neohypopharynx, http://links.lww.com/PRSGO/A454).

Fig. 1.

The skin paddle of the ALT flap for tubularization was extended distally into a fusiform shape with the distal part prepared for externalization. The distal skin paddle was cut through the dermis with the subcutaneous tissue and fascia attached to the main flap. The distal skin paddle remained well perfused while waiting for the tumor ablation surgery.

We describe an illustrative case of the creation of a neohypopharynx by using ALT flap after radical neck dissection and total pharyngolaryngectomy (see figure, Supplemental Digital Content 3, which displays the hypoharyngeal defect after radical neck dissection and total pharyngolaryngectomy, http://links.lww.com/PRSGO/A454). For monitoring purpose, the distal skin paddle was folded, externalized, and stayed above the tracheal stoma (see figure, Supplemental Digital Content 4, which shows that for monitoring purpose, the distal skin paddle was folded, externalized, and stayed above the tracheal stoma, http://links.lww.com/PRSGO/A454). The distal skin paddle regained its normal perfusion after microvascular anastomosis (see figure, Supplemental Digital Content 5, which demonstrates that distal cutaneous stump of the tubed ALT flap functioned well as a reliable monitoring skin paddle, http://links.lww.com/PRSGO/A454). Healing of the externalized distal skin paddle to native neck skin was good despite previous irradiation (Fig. 2). Recovery was uneventful, and the patient could tolerate most regular food. Esophagography demonstrated a patent neohypopharynx with no evidence of stricture or fistula (see figure, Supplemental Digital Content 6, http://links.lww.com/PRSGO/A454).

Fig. 2.

Three weeks after the reconstruction, the healing of this distal paddle to the native neck skin was good despite previous neck irradiation.

Suprastomal externalization of a distal skin paddle of the tubed ALT flap is a technically simple and reliable method for the monitoring of this buried free flap.