Complex intraoperative defect planning flexibility—Post-salvage laryngectomy defect reconstruction with a double skin-paddled radial forearm free flap

Abstract

Reconstruction of pharyngoesophageal defects following total laryngectomy poses a significant challenge. The goals of reconstruction are to provide alimentary tract continuity and to restore speech and swallowing functions. Patients with radiotherapy recurrent disease often have unfavourable tissue for healing with a high incidence of pharyngocutaneous fistula. We discuss utilisation of a double skin paddle radial forearm free flap for pharyngoesophageal reconstruction as well as a cutaneous skin defect.A 53-year-old female was referred to our department for reconstruction of her total laryngectomy defect secondary to radio-recurrent right laryngeal squamous cell carcinoma with extra-laryngeal spread.Reconstruction planning was challenging as the patient was an obese, heavy smoker with significantly irradiated neck skin. A tubed radial artery forearm free flap was planned for pharyngoesophageal reconstruction however due to the extent of radiotherapy skin damage; primary closure of the neck defect was not possible. The flap was modified into a double paddle design to reconstruct the pharyngoesophageal defect, with the second skin paddle folded over to reconstruct the cutaneous defect.Multiple reconstructive options have been described in the literature for primary laryngectomy defects. Complex patients with recurrence particularly after neoadjuvant treatment are often poor candidates for reconstruction with poor tissue viability. Providing sufficient and adequate soft-tissue coverage is essential to minimise complications. We have described an intra-operatively planned, novel technique of reconstruction. Pre-operative anticipation may assist in addressing complexities encountered particularly in settings of hostile native skin.