Using a Fabricated Forearm Free Flap for Simultaneous Reconstruction of Cervical Esophageal Circumferential Defect and Speech Function

Abstract

Sir: Reconstruction of defects resulting from extensive oncologic surgery of the cervical aerodigestive track in advanced hypopharyngeal cancer is one of the most challenging procedures. In these patients, both functional swallowing and voice restoration are important.1 A 60-year-old man was admitted to our ward in February of 2005 because of a 5-cm nodule (squamous cell carcinoma) over the posterior pharyngeal wall. The stage of the tumor was T3N0M0. After ablative surgery, a 10-cm segmental defect of the cervical esophagus was noted. A fabricated forearm flap was designed based on the defect and the expected length of the phonation tube (Fig. 1). The flap was elevated using the standard method, and the skin paddles of the phonation tube and esophageal tube were repaired with fine Dexon suture to make it a tube (Fig. 2). The esophageal tube was used to replace the cervical esophageal defect. The phonation tube is placed as a curvilinear shape to reduce the amount of retrograde leakage (Fig. 3). The distal part of the phonation tube was placed beside the orifice of the permanent tracheostomy. Microanastomosis was performed with 10-0 nylon. The flap was monitored by the distal part of the phonation tube (Fig. 3).Fig. 1.: Drawing showing the design of the fabricated forearm free flap. The skin flap included two parts, the phonation tube (right) and the esophageal part (left), and was connected with tracheoesophageal puncture. a, 10-cm length of esophageal defect; b, 6-cm circumference of esophagus; c, 2-cm circumference of tracheoesophageal puncture; d, 8-cm circumference of oropharynx; e, 6-cm circumference of outer orifice of phonation tube.Fig. 2.: The esophageal part was rolled be a tube to replace the segmental cervical esophageal defect. The phonation tube (15 cm) was placed as a curvilinear shape. The distal part of the phonation tube was placed beside the orifice of the permanent tracheostomy.Fig. 3.: Transplantation of flap to the neck. The outer orifice of the phonation tube was placed beside the orifice of the permanent tracheostomy, where we could also monitor the flap.The fabricated forearm free flap survived uneventfully and the patient started his diet smoothly (liquid then solid diet) 3 weeks after the operation. The patient refused chemotherapy or radiotherapy. Two years later, he could still take a full diet without any difficulty. The phonation was obtained by diverting the expiratory airflow through the phonation tube to pass the tracheoesophageal puncture into the neoesophagus (Fig. 4) and evaluated by the ability of voice production, phonation efficacy, maximal phonation time per breath, loudness, and grading of wet voice. Speech intelligibility was evaluated by Hirose's classification,2 a five-point rating scale.Fig. 4.: Close-up view of the outer orifice of the phonation tube, 1 year after surgery.Regarding phonation and speech outcomes, the patient was able to produce sounds vocally 3 weeks after surgery. Eighteen months later, the phonation efficacy was 95 percent and the maximal phonation time was more than 6 seconds. The wet voice was graded as mild and the loudness was decreased mildly. The pitch was low and vocal fry sometimes occurred. Regarding speech outcome, the range of number counting was over 15. He could speak at least three syllables per breath. The speech intelligibility of this patient was classified as excellent. Two types of free flaps have been used for reconstruction of advanced cancer of the hypopharynx: the intestinal flap and the fasciocutaneous flap.3–5 Since the 1980s, the radial forearm free flap has been used for single-stage reconstruction of defects after laryngopharyngectomy,4 and it was proved to be a reliable reconstruction. Options for voice restoration with surgical procedures in pharyngolaryngectomized patients include tracheoesophageal puncture and tracheojejunal puncture, with or without prosthesis.1,5 In advanced hypopharyngeal carcinoma, the ileocecal valve in ileocolic flap reconstruction3 and the functional tracheopharyngeal shunt in jejunal flap reconstruction5 have also been used. In this report, besides the restoration of swallowing function, we used a phonation tube based on the same fabricated forearm free flap. After 2 years, this patient showed excellent swallowing and could take an ordinary diet. The phonation tube leakage was mild. The phonation efficacy was high and the speech outcome was satisfactory. Shih-Hsin Chang, M.D. Kwang-Yi Tung, M.D. Hung-Tao Hsiao, M.D. Department of Plastic and Reconstructive Surgery Mackay Memorial Hospital Taipei, Taiwan Jehn-Chuan Lee, M.D. Department of Otolaryngology Mackay Memorial Hospital Taipei, Taiwan Cheng-Chien Yang, M.D. Department of Otolaryngology Mackay Memorial Hospital, and Department of Speech and Hearing Disorders and Sciences National Taipei College of Nursing Taipei, Taiwan