A Simplified Design of a Dual Island Fasciocutaneous Free Flap for Simultaneous Pharyngoesophageal and Anterior Neck Reconstruction

Abstract

Reconstruction of the pharyngoesophagus and pharynx can be especially challenging in patients with prior irradiation, recurrent disease, and compromised or deficient anterior neck skin. The authors report their experience with seven patients who underwent pharyngoesophageal reconstruction with a new flap design that addresses both the concerns of monitoring the internal skin tube and replacing the external neck skin with one flap. This design has two skin islands, one that is tubed and the other left flat. The authors call this design "the paddle flap" because together its two components resemble a paddle. The tubed portion resembles the "handle" of a paddle that is used for esophageal reconstruction, and the cutaneous paddle is then folded over the "handle" to provide external skin. The external skin portion of the flap not only provides an external monitoring segment but releases tension on the neck apron incision and may replace compromised native neck skin. The length of esophageal defects ranged from 4 to 11 cm and the anterior cervical skin requirements ranged from 4 x 2 cm to 10 x 12 cm. Follow-up has been between 18 months and 4 years. There were no partial or complete flap losses. All patients are currently tolerating an oral diet. There was one case of partial donor-site skin graft loss which was treated with re-grafting. There were two cases of stricture formation which were treated successfully with neo-esophageal dilatation. This new simple, versatile design of a cutaneous free flap addresses both concerns of monitoring the internal skin tube and dealing with compromised overlying skin in patients undergoing pharyngoesophageal reconstruction. The paddle flap design can be utilized with any thin cutaneous free flap and may offer an advantage when an external monitor is desired and anterior neck skin requires supplementation or replacement.