We read with great interest the article on pharyngoesophageal reconstruction and neck resurfacing by Sharaf et al.1 This multicenter study, based on a large caseload, highlights the complexity of pharyngoesophageal reconstruction, especially in case of salvage surgery after failed organ-preservation therapy using chemoirradiation. As clearly reported in this article, excessive scarring and hypovascularity of neck tissues may seriously compromise reconstructive outcomes because of suboptimal healing of neck soft tissues. Among the most frequent complications, there are pharyngocutaneous fistulas, wound dehiscence around the tracheostoma, and skin necrosis.2–4 Depending on comorbidities, these complications can be experienced in up to 60 percent of patients.2–4 In this setting, prompt management is required, as wound complications may start a cascade of major complications that are difficult to predict and to manage.
Sharaf et al. demonstrated that, by providing additional vascularized soft tissue for neck resurfacing, the aforementioned complications are dramatically reduced. Based on their experience, they suggested a reconstructive algorithm. This is mainly based on chimeric adipocutaneous and/or muscle flaps of the lateral circumflex femoral artery system, where one adipocutaneous flap is used for neoconduit reconstruction and the second flap is used for neck resurfacing. The rationale for this method is to have a single set of microvascular anastomoses to perform, which is advantageous, as those complicated cases usually share vessel-depleted necks. The further advantage is to use the neck-resurfacing flap as a monitor, especially if it remains “downstream” of the blood supply.
When lateral circumflex femoral artery flaps are not appropriate, they suggest two-paddle forearm flaps. When lateral circumflex femoral artery or forearm chimeric flaps are not available, they suggest local flaps such as supraclavicular or pectoralis major muscle/myocutaneous flaps.
In our experience, we usually perform these reconstructions by using lateral circumflex femoral artery chimeric adipocutaneous flaps (usually an anterolateral thigh free flap with two perforators) for neoconduit reconstruction and neck resurfacing/skin monitor. However, when a second favorable perforator is not found, the internal mammary artery perforator propeller flap is our favorite option for neck resurfacing.
Besides the same benefit of the free flap, we believe that the propeller internal mammary artery perforator carries further advantages as follows: (1) large and very long, thin, pliable flap with a texture similar to that of the neck able to reach up to the submental area if based on a perforator of the first intercostal space; (2) reliable skin vascularity rarely prone to venous congestion as also demonstrated by perfusion studies5; (3) reduction of microvascular complications related to the insetting of chimeric flaps such as kinking and torsion; (4) possibility of providing sensate soft-tissue coverage in the neck by preserving cutaneous nerves accompanying the selected perforator; and (5) reduced donor-site morbidity by favoring primary closure both in the thigh and in the pectoralis area (Fig. 1).
We believe that the internal mammary artery perforator flap is also preferable to the pedicled pectoralis major myocutaneous flap because the latter is too bulky for neck soft-tissue resurfacing and cannot be thinned primarily, thus risking impinging on the tracheostoma. Moreover, its skin paddle is smaller and less reliable, and the donor-site morbidity is higher, usually needing a skin graft compared with the internal mammary artery perforator flap.
One of the major limitations of this flap involves female patients, because a significant breast deformity will be created, especially if a very large internal mammary artery perforator flap is harvested. In female patients, we prefer other local flaps such as the supraclavicular flap or free flap.
The authors have no financial interest to declare in relation to the content of this communication.
Marzia Salgarello, M.D.Department of Plastic and Reconstructive Surgery
Giovanni Almadori, M.D., Ph.D.Department of Head and Neck Surgery
Giuseppe Visconti, M.D.Department of Plastic and Reconstructive SurgeryUniversità Cattolica del “Sacro Cuore”University Hospital “A. Gemelli”Rome, Italy
1. Sharaf B, Xue A, Solari MG, et al. Optimizing outcomes in pharyngoesophageal reconstruction and neck resurfacing: 10-year experience of 294 cases. Plast Reconstr Surg. 2017;139:105e119e.
2. Sassler AM, Esclamado RM, Wolf GT. Surgery after organ preservation therapy: Analysis of wound complications. Arch Otolaryngol Head Neck Surg. 1995;121:162165.
3. Weber RS, Berkey BA, Forastiere A, et al. Outcome of salvage total laryngectomy following organ preservation therapy: The Radiation Therapy Oncology Group trial 91-11. Arch Otolaryngol Head Neck Surg. 2003;129:4449.
4. Ganly I, Patel S, Matsuo J, et al. Postoperative complications of salvage total laryngectomy. Cancer 2005;103:20732081.
5. Wong C, Saint-Cyr M, Rasko Y, et al. Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap. Plast Reconstr Surg. 2009;124:17591769.