#15 Scalpel

Allis forceps

Appropriate sutures

Cat’s paw retractors

Dissecting forceps

Dissecting scissors

Freer elevator

Langenbeck retractors

Local anesthetic with vasoconstrictor

Monopolar and bipolar electrocautery

Nasogastric tube

Needle holder

Skin hooks

Suction drains of choice

Tooth and nontooth Adson forceps

Introduced by Ariyian in 1979

First used by Whiters and colleagues in the same year for reconstruction of circumferential hypopharyngeal defects in a tubed form

Partial defects in the pharyngeal mucosa (the width of the flap is decided by the width of the remnant pharyngeal mucosa)

Circumferential defects in the pharyngeal mucosa (the width of the flap required is 8 to 10 cm)

Resection margin reaching beyond the thoracic inlet

Defects longer than 11 to 12 cm

Operating time is reduced, which is especially important among emaciated and fragile hypopharyngeal cancer patients

Fan-shaped muscular portion of the flap is helpful for protecting the carotid artery, especially in post-radiotherapy patients

No microsurgical training is required

The flap donor site can be closed primarily with minimal morbidity

This flap provides a suboptimal reconstructive choice when a significant part of the base of tongue or the lateral oropharyngeal wall has been resected; the weight and the downward traction of the flap significantly impair the mobility of the tongue, resulting in degradation of augmented speech and poorer swallowing function

The bulkiness of the flap makes it difficult to be sutured at the relatively narrow cervical esophageal stump, resulting in circumferential stenosis; this can be partially overcome by performing interdigitations to provide a zigzag configuration at the distal anastomosis

The bulkiness and rigidity of the PMMC flap reduce its vibratory properties, resulting in poor phonatory outcomes

The flap can result in distortion and blocking of the tracheostoma in obese patients and patients with a short neck

For circumferential defects, the three-point closure sites are prone to fistula formation and subsequent stenosis

Complication rates in relation to stenosis and pharyngocutaneous fistula are higher as compared to free flaps

May result in significant breast deformity in female patients

As the muscle bulk sometimes prevents complete tubulization, Fabian and Spriano and colleagues modified the technique by using a U-shaped reconstruction of the circumferential hypopharyngeal defect by suturing the flap edges to the prevertebral fascia, either covering the fascia by a skin graft or leaving it bare

The PMMC flap can be considered a reconstructive option for thin male patients with partial hypopharyngeal defects and significant comorbidity where a prolonged operative time is to be avoided

Introduced by Yang and colleagues in 1981

Used for hypopharyngeal reconstruction for the first time in 1985 by Harii

Partial defects in the pharyngeal mucosa

Circumferential defects in the pharyngeal mucosa

The pharyngocutaneous fistula rates are lower than those with the PMMC flap and comparable with other free flaps

Its long vascular pedicle, low donor site morbidity, good caliber vessels, tolerance to long ischemia times, and relative ease in harvesting make it a good option for pharyngeal reconstruction

The radial artery and the cephalic vein have a certain degree of independence from each other, which makes microvascular anastomosis possible on recipient vessels located at considerable distance from each other, even on opposite sides of the neck

A skin island of up to 12 to 14 cm ² can easily be harvested without donor site problems

The good pliability of the flap has a definite advantage over PMMC and anterolateral thigh (ALT) flaps, especially among obese patients, resulting in superior voice and swallowing outcome

The low volume of the flap does not hamper primary closure of the neck

Hair growth even in men is exceedingly low on the volar aspect of the forearm as compared with the thigh and the chest

Potential donor site morbidities including tendon exposure, partial loss of skin graft, hypovascularization with cold intolerance, and transient or permanent numbness of the first two fingers and dorsum of hand

The flap does not provide muscle for covering the carotids or reinforcing the pharyngeal closure

Three-point closure is required for circumferential defects

Partial defects in the pharyngeal mucosa

Circumferential defects in the pharyngeal mucosa

The pharyngocutaneous fistula rate of the ALT flap is lower than that observed in RFFF; this may be related to the generous amount of vascularized fascia lata that can be harvested with the flap, which can be used as a second layer closure; a lower fistula rate is associated with a lower rate of stenosis formation

In selected patients, an extensive portion of the vastus lateralis muscle can be harvested with the skin or independently, and it can be used for a second layer closure over the suture line or for protecting the great vessels of the neck

Large skin paddles or two separate skin paddles can be harvested with minimal donor site morbidity

Remoteness of the thigh from the head and neck makes the two-surgical-team approach possible, thus reducing the operating time

As hypopharyngeal cancer patients are frequently emaciated, they have decreased thigh bulk, which facilitates tubing the flap for circumferential defects

The diameter of the tubed flap corresponds well with the diameter of the remnant oropharyngeal mucosa in circumferential defects

In obese patients, the bulk of the flap impairs the vibratory property of the neopharynx, resulting in poor speech

Mismatch in lumen diameter between the tubed flap and the cervical esophagus in circumferential defects

Three-point closure is required for circumferential defects

Diameter of the jejunum matches with the esophageal stump mucosa

For circumferential defects, there is no three-point closure, as required in tubed fasciocutaneous or PMMC flaps

Mucosa is replaced by mucosa

Intrinsic peristaltic activity of the jejunum helps in bolus propulsion; however, the initial peristaltic movements are not coordinated, and patients usually complain of dysphagia in the early postoperative period

Perioperative donor site complications are high; mortality ranges from 0% to 17% (mean, 2.5%), which is four times higher than for fasciocutaneous free flaps; morbidities of an abdominal surgery include bowel obstruction, abdominal bleeding, acute gastric dilatation, superior mesenteric syndrome, laparocele, wound infection or dehiscence, abdominal wall hematoma, and prolonged ileus

Limited ischemic tolerance of the jejunal flap commonly results in partial necrosis, pharyngocutaneous fistula, and subsequent stenosis.

The length of the vascular pedicle (10 to 15 cm) is roughly half that usually observed in RFFF and ALT free flaps

Voice (in patients with a tracheoesophageal puncture) is usually “wet and gurgly”

Tolerance of the jejunum to radiotherapy is only 50 Gy, which is lower than the recommended dose of postoperative adjuvant radiotherapy in head and neck cancer patients

Three intestinal and two microvascular anastomoses are required

The flimsy and friable nature of vessels (particularly the vein) as compared to fasciocutaneous flaps.

There is a frequent mismatch in diameter at the pharyngeal end

External skin defect, if present, requires another flap

The main advantage over a jejunal free flap is the provision of a generous amount of highly vascularized greater omentum to be draped around the neopharyngeal conduit, covering the great vessels and filling dead space

Length of gut that can be obtained is about 30 cm

Good caliber vessels and superb independent mobility of the gastroepiploic vascular pedicle

Gastro-omental free flap is currently recommended in the management of

select, complicated high-risk conditions in which a generally healthy patient (able to withstand the potential complications of an abdominal procedure) is associated with a serious local wound problem owing to infection, hypovascularization, or necrosis

One-stage procedure and a single intestinal anastomosis required

No microvascular expertise required

Complications of abdominal surgery as previously mentioned

Gastric reflux and early satiety

Introduced by Ariyian in 1979

First used by Whiters and colleagues in the same year for reconstruction of circumferential hypopharyngeal defects in a tubed form

Partial defects in the pharyngeal mucosa (the width of the flap is decided by the width of the remnant pharyngeal mucosa)

Circumferential defects in the pharyngeal mucosa (the width of the flap required is 8 to 10 cm)

Resection margin reaching beyond the thoracic inlet

Defects longer than 11 to 12 cm

Operating time is reduced, which is especially important among emaciated and fragile hypopharyngeal cancer patients

Fan-shaped muscular portion of the flap is helpful for protecting the carotid artery, especially in post-radiotherapy patients

No microsurgical training is required

The flap donor site can be closed primarily with minimal morbidity

This flap provides a suboptimal reconstructive choice when a significant part of the base of tongue or the lateral oropharyngeal wall has been resected; the weight and the downward traction of the flap significantly impair the mobility of the tongue, resulting in degradation of augmented speech and poorer swallowing function

The bulkiness of the flap makes it difficult to be sutured at the relatively narrow cervical esophageal stump, resulting in circumferential stenosis; this can be partially overcome by performing interdigitations to provide a zigzag configuration at the distal anastomosis

The bulkiness and rigidity of the PMMC flap reduce its vibratory properties, resulting in poor phonatory outcomes

The flap can result in distortion and blocking of the tracheostoma in obese patients and patients with a short neck

For circumferential defects, the three-point closure sites are prone to fistula formation and subsequent stenosis

Complication rates in relation to stenosis and pharyngocutaneous fistula are higher as compared to free flaps

May result in significant breast deformity in female patients

As the muscle bulk sometimes prevents complete tubulization, Fabian and Spriano and colleagues modified the technique by using a U-shaped reconstruction of the circumferential hypopharyngeal defect by suturing the flap edges to the prevertebral fascia, either covering the fascia by a skin graft or leaving it bare

The PMMC flap can be considered a reconstructive option for thin male patients with partial hypopharyngeal defects and significant comorbidity where a prolonged operative time is to be avoided

Introduced by Yang and colleagues in 1981

Used for hypopharyngeal reconstruction for the first time in 1985 by Harii

Partial defects in the pharyngeal mucosa