Laryngopharyngectomy Reconstruction: Quo Vadis?

Abstract

Cancer of the hypopharynx and larynx remains a deadly disease, often owing to diagnosis late in its progression. Neoadjuvant chemoradiotherapy has superseded the more aggressive options of primary extensive resection, although, a small portion of cases, especially those that recur, present a therapeutic challenge. Salvage total laryngectomy or laryngopharyngectomy are the operations of choice. Broadly, reconstruction of the hypopharynx and larynx can be categorized based on the following requirements: cover of a partial or circumferential defect, restoration of swallowing and/or speech, patient co-morbidities, previous radiotherapy to the recipient site, and the indication for flap as a result of trauma, or tumour resection [1]. The ideal reconstruction involves recreation of a digestive conduit with vascularized tissue that enables early restoration of swallowing and speech while minimizing complications such as fistula, stricture, anastomotic site leakage, or flap necrosis. Single stage reconstructions are preferred for minimal morbidity and mortality. The two common options used for reconstruction are pedicled or free flaps. For reconstruction of the pharynx, the options for pedicled flaps include pectoralis major myocutaneous flap (PMMC), latissimus dorsi myocutaneous flap (LDMC), sternocleidomastoid, trapezius, submental, thoracodorsal artery perforator (TDAP), and supraclavicular artery flaps. Free flap options can be divided into two groups: fasciocutaneous flaps -anterolateral thigh flap (ALT) or radial forearm free flap (RFFF), and visceral flaps -gastroomental or jejunal free flap. With regards to reconstruction of the larynx, similar options are considered, with inclusion of the temporoparietal free flap (TPFF). Whilst these operations can maintain a reasonable degree of functionality and improved oral intake, both are often beset with the complications mentioned above, often deterring many a good reconstructive microsurgeon.The choice of flap is influenced by whether the defect is created following primary surgery or is a salvage procedure performed for recurrent disease following radiotherapy. In addition, reconstruction of a cartilaginous structure is often fraught with failure due to its non-vascularized nature and often requires augmentation with a vascularized carrier : this may need to be performed in two stages