MICROSURGERY

Functional Outcome Analysis After Anterolateral Thigh Flap Reconstruction of Pharyngoesophageal Defect Tsung-Chun Huang, MD, Yung-Chang Hsu, MD, Hung-Chi Chen, MD, Sophia Chia-Ning Chang, MD, and Hsin-Han Chen, MD Background: Pharyngoesophageal defects are traditionally reconstructed with jejunal or radial forearm f laps. Recently, anterolateral thigh f laps have served for pharyngoesophageal reconstruction. We tell of our experience with anterolateral thigh f lap for the reconstruction of pharyngoesophageal defect for the past 5 years. This study presents another modified f lap design and refinement of surgical techniques. Methods: In all, 45 pharyngoesophageal reconstructions were performed during 2006 to 2011, namely patch (n = 18), near-circumferential (n = 8), and circumferential defect (n = 19) reconstructed by 2 plastic surgeons with the same trapezoid anterolateral thigh f lap design. Results: Total f lap loss occurred in 2 patients (4%). Two patients experienced partial f lap necrosis. Fistulas occurred in 8 patients, but only 5 of these needed further suture ligation or local flap treatment. Postoperative strictures without tumor recurrence were identified in 4 patients (9%). Forty patients (88.9%) could tolerate oral diet; 34 of these ate soft or solid food. Conclusions: Anterolateral thigh f lap offers good coverage and swallowing function in the reconstruction of hypopharyngeal defect. Trapezoid drawing of anterolateral thigh f lap makes the design simplified, with an accepted complication rate. Key Words: pharyngoesophageal reconstruction, anterolateral thigh flap, laryngopharyngectomy, pharyngocutaneous fistula, hypopharyngeal reconstruction (Ann Plast Surg 2015;75: 174Y179)

P

haryngoesophageal defect reconstruction poses a challenge to plastic surgeons. Ideal procedure yields low complication, minimal donor-site morbidity, and short hospital stay and restores swallowing and speech function. Radiotherapy is usually required, either before or after total laryngectomy or esophagectomy, making reconstruction more difficult, especially in patients with late-stage hypopharyngeal cancer. In the past, jejunal flap and radial forearm flap were the most common methods. However, limitation of jejunal flap is the major donor-site risk in patients with comorbid disease.1 Radial forearm flap was frustrated by higher fistula rate compared to jejunal flap and by limited tissue volume.2,3 Recently, anterolateral thigh (ALT) flap has gained popularity in some institutions.1,4Y6 Compared with jejunal flap, ALT flap has not only comparable low stricture and fistula formation rate but also good swallowing function without intra-abdominal complications. We present our 5-year experience in pharyngoesophageal defect reconstruction by ALT musculocutaneous flaps. Clinical and functional outcomes were retrospectively analyzed. Received June 20, 2013, and accepted for publication, after revision, October 28, 2013. From the Department of Plastic and Reconstructive Surgery, China Medical University Hospital China Medical University, Taichung, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Hsin-Han Chen, MD, Division of Plastic Surgery, China Medical University Hospital, No. 2 Yuh Der Rd, Taichung City, 40447, Taiwan. E-mail: [email protected]. Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7502-0174 DOI: 10.1097/SAP.0000000000000073

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MATERIALS AND METHODS A retrospective review included 45 patients with hypopharyngeal cancer who received pharyngoesophageal reconstruction by free ALT musculocutaneous flap at the Department of Plastic and Reconstructive Surgery in China Medical University Hospital from April 2006 to December 2011. There were 44 men and 1 woman, with a mean (standard deviation [SD]) age of 57 (12) years. The pathological diagnoses include primary (64.5%), recurrent (31.1%), and secondary primary (2.2%) squamous cell carcinoma and sarcomatoid carcinoma (2.2%) in the larynx or hypopharynx. There were 40 patients with advancedstage (stage III-IV) cancer. Before surgery, 37.8% of the patients had undergone radiotherapy. Major medical comorbidities included diabetes mellitus (22.2%), hypertension (15.6%), cardiopulmonary disease (6.6%), liver cirrhosis (4.2%), and cerebral vascular accident (2.2%). In this series, 18 cases were classified as patch defect and 27 were near-circumferential or circumferential defect.

Flap Design and Harvesting The f lap was designed and harvested simultaneously with tumor ablation surgery by a 2-team approach, with perforators localized by Hand-held Doppler. Patch defect was determined with the wound defect size. The design of the skin paddle for circumferential defect (Fig. 1) was drawn as a trapezoid (Fig. 2, left). The length of the longer base is equal to the perimeter of the proximal defect, and the length of shorter base is the same as the perimeter of the distal cervical esophagus. The height of the trapezoid equals the length of the hypopharyngeal defect. A cuff of the vastus lateralis (VL) muscle was harvested, with the ALT f lap as spacer and monitor for the f lap. After tumor ablation surgery, the ALT musculocutaneous f lap was taken down (Fig. 2, right). Upper and lower anastomoses were performed first with 3-0 vicryl interrupted suture. At the same time, a nasogastric (NG) tube from the nose to the stomach was inserted and was wrapped around by the f lap, and another NG tube from the other nose orifice to the lower anastomosis area was inserted to aspirate saliva (Fig. 3, left). Then we performed microsurgery anastomosis for the branch of the internal jugular vein to the pedicle followed by superior thyroid artery to the pedicle. The facial artery, the transverse cervical artery, and the external jugular vein were chosen as alternatives if the internal jugular vein or the superior thyroid artery was sacrificed during tumor resection. After microsurgery, the residual defect of the f lap was closed with 3-0 interrupted sutures. A fibrin sealant (Tissucol) reinforced the proximal and distal anastomoses and the longitudinal suture line of the neopharynx. The fascial layer from the ALT f lap was sutured to reinforce the suture line (Fig. 3, right). The VL muscle was used as a spacer (Fig. 4, left), and 1 piece of the VL muscle was pulled out as a monitoring window (Fig. 4, right). For drainage, 2 Jackson-Pratt drains were inserted in each side of the neck and the neck was closed layer by layer, as donor site was, primarily (Fig. 5). A 3-year follow-up of the contour manifested an acceptable appearance (Fig. 6).

Statistical Analysis Continuous variables are expressed as means and SDs. Fisher exact and t tests were used for statistical comparisons, and 2-tailed P G 0.05 was considered significant. Annals of Plastic Surgery

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FIGURE 1. Typical circumferential hypopharyngeal defect from the distal cervical esophagus to the tongue base.

RESULTS We found 19 circumferential, 8 near-circumferential, and 18 patch defects. Mean (SD) intensive care unit stay was 5 (2) days (range, 3Y13 d), ventilator stay was 3 (2) days (range, 1Y9 d), and hospital stay was 24 (10) days (range, 13Y64 d). The primary closure rate of donor-site defect tallied 88.9%, and the remainder was covered with split-thickness skin graft harvested from the contralateral thigh area, without donor-site complication. Postoperative radiotherapy was performed on 28 patients (62.2%). Mean (SD) follow-up time was 29 (18) months (range, 3Y91 mo). Total f lap failure occurred in 2 cases (4.4%): one from the arterial thrombus and the other by vein congestion. The first was salvaged by gastric pull-up procedure with more than a 5-year survival, whereas the second was reconstructed by pedicle transverse colon f lap; the latter died because of septic shock and acute respiratory distress syndrome. Partial f lap failure occurred in 2 patients, both characterized by marginal f lap necrosis and infection. One was covered by split-thickness skin graft after debridement, the other reconstructed by another tubed ALT f lap. Esophagography was performed in 40 patients (88.9%) after a mean (SD) of 14.7 (4.0) days (range, 10Y28 d). Mean (SD) formation time of fistula after reconstruction was 56 (46) d (range, 18Y120 d). Fistulas occurred in 8 patients, with only 5 (11.1%) needing further suture ligations or local f lap treatments (Table 1). About one third of the fistula healed spontaneously after a mean (SD) time of 32 (23)

Trapezoid-Shaped ALT Flap Tubing

days (range, 18Y58 d), with no statistical significant difference between circumferential and patch defect groups (Fisher exact test, P = 0.694; Table 2). On the other hand, 4 of 14 patients with contrast leakage during esophagography developed fistulas; another 4 fistulas were identified afterward, without initial contrast leakage. The sensitivity of esophagography for the detection rate of fistula was 50%, and specificity was 69% (Table 1). Excluding 2 local recurrent tumor cases, postoperative stricture confirmed by esophagography appeared in 4 patients (9.3%) in 6.3 T 7.9 (range 1Y18) months. All strictures occurred in distal anastomosis. Of two patients receiving panendoscope balloon dilatation, 1 tolerated semisolid food. Three strictures occurred in circumferential defect, and 1 occurred in patch defect. There was no statistically significant difference between groups (Fisher exact test, P = 0.640) (Table 2). Table 3 correlates radiation with complications of fistula, with stricture shown. Postoperative radiotherapy was required in 62.2% of cases, with 42 patients exposed to radiotherapy either before or after reconstruction. No significant difference in stricture or fistula formation appeared between the radiation group postoperatively and the nonradiation group (fistula, P = 1.000; stricture, P = 0.144). Diet function was rated by best swallowing records from the retrospective chart review: 40 patients (88.9%) tolerated their oral diet, with 34 of them (75.6%) eating soft or solid food (Table 4). Five patients were tube-fed; 2 with partial and 3 with circumferential defects. One of them had total f lap loss salvaged by colon f lap reconstruction, and 4 died within 1 year. Tubing diet had a significant difference associated with radiation exposure either before or after operation (P = 0.029). In this study, pneumatic artificial larynx was used for pronunciation after reconstruction; patients spoke with clear and wellunderstood words.

DISCUSSION Fistula formation spawns complications at the anastomosis site of pharyngoesophageal reconstruction in both musculocutaneous and jejunal f laps.7 In recent years, radial forearm f lap has been viewed less favorably because of the high fistula formation rate (17%Y 50%).8Y11 On the other hand, ALT f lap shows great advantages and potential for a key role in hypopharyngeal reconstruction in even more case series. Yu et al1 demonstrated the largest series, in which fistula rate can drop to 9%, comparable to the rate (range, 8%Y22%) in previous free jejunal f lap series.7,12Y14 Stricture is another common complication after neopharynx reconstruction. The reported stricture rate in both methods ranged from 15% to 23% after jejunal

FIGURE 2. Anterolateral thigh f lap was harvested with a trapezoid design. The longer and shorter bases were measured by the perimeter of the tongue base and by the perimeter of the distal esophagus, respectively. The height of the f lap was equal to the length of the neopharynx. A, Pre-operative design and (B) after harvesting. * 2013 Wolters Kluwer Health, Inc. All rights reserved.

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FIGURE 3. A, Anterolateral thigh f lap was rolled as a tube-shaped neopharynx with vastus lateralis muscle as an extra spacer, and (B) the fascia of the ALT f lap was rolled over to cover the neopharynx with a second layer for suture reinforcement.

FIGURE 4. A, Vastus lateralis muscle was harvested as a spacer, and (B) a piece of vastus lateralis muscle was pulled out as a monitoring window.

f lap reconstruction12,15,16 and varied from 6% to 18% after ALT f lap reconstruction1,5,6,17 individually. To this day, 2 main designs of ALT f lap have been reported: 2 skin islands designed with extended lip of skin5 and elliptical skin paddle methods.6 In this study, we presented a newer, simplified design with trapezoid ALT f lap and refinement procedure, with similarly good outcomes. Eight cases suffered from fistulas, but

FIGURE 5. Donor site was usually primarily closed. 176

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surgical intervention for this complication only compromised 11.1% of all patients. Approximately one third of fistulas heal spontaneously within a mean of 4.4 weeks, much sooner than the free jejunal f lap.7 Our comparable outcomes from this simplified design may be attributed to the 2 NG tubes, use of fibrin sealant, fascia reinforcement, and muscle spacer. To avoid fistula formation, we applied 1 NG tube for neopharynx stenting, and the other NG tube was kept at the lower anastomosis area for draining the aspirated saliva. After ALT f lap tubing, the fibrin sealant was sprayed over proximal and distal anastomoses and along the longitudinal suture sites to decrease leakage.18,19 Fascia reinforcement can also alleviate saliva leakage. Muscle spacer can decrease infection and seroma formation. All these explain some of our fistulas spontaneously healing locally. In hypopharyngeal reconstruction, esophagography is the main tool to screen complications, but our data showed limited sensitivity and specificity to detect fistula formation. A trapezoid designed ALT flap also showed acceptable stricture rate (9.3%); all such cases can tolerate oral diet, and only 2 needed balloon dilatation, probably because of the wider inlet in the swallowing process in our trapezoid design. The other feature of stricture in most of the related articles revealed dysphagia predominantly occurring in the circumferential defect and at the distal anastomosis, both compatible with our results. Circular scar contracture is probably the main reason.5,6 This hypothesis was supported, since the same results can be derived from 3 different design studies, yet with no significant difference (P = 0.640) between circumferential and patch groups. * 2013 Wolters Kluwer Health, Inc. All rights reserved.

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Trapezoid-Shaped ALT Flap Tubing

FIGURE 6. Well-healed pharyngoesophageal reconstruction with anterolateral thigh f lap at 3 years 2 months of follow-up exhibits acceptable appearance. A, Anterior view and (B) oblique view.

TABLE 1. Analysis of Esophagography Esophagography (n = 40)

Fistula Formation

No Fistula

Contrast leakage (n = 14)

Upper (n = 2)* Upper (n = 5) Lower (n = 1)* Lower (n = 5) Anterior chest wall (n = 1)* No contrast leakage (n = 26) Upper (n = 1), lower (n = 3)† n = 22 No esophagography was applied in 5 patients: 1 died because of acute respiratory distress syndrome and the other 4 patients had a mean follow-up of 2 years 10 months without fistula and stricture. Upper indicates upper anastomosis (between upper inlet and f lap). Lower indicates lower anastomosis (between f lap and lower outlet). Sensitivity, 50%; specificity, 69%. *Fistulas (n = 4) of the contrast leakage group were treated with suture and local f lap. †One of 3 lower fistulas was treated with sutures and the other 3 fistulas spontaneously healed.

ALT f lap reconstruction offers favorable swallowing function, with minimal donor-site complications (Table 5); 89% of our patients achieved oral diet without tube feeding. Compared with the results of Yu et al1 (91%) and Spyropoulou et al6 (69%), we demonstrate even better outcome because we did not exclude recurrence and total f lap failure cases. On the other hand, jejunal f lap showed variable (59%Y88%) nutritional outcomes.4,12,14 Another disadvantage of jejunal f lap is major donor-site morbidity. Most patients are tobacco

TABLE 4. Radiation Effect on Diet Prior XRT (+)

Prior XRT (j)

Post-OP XRT Yes (n = 4) No (n = 14) Yes (n = 24) No (n = 3) Total Tube diet Oral diet Liquid Soft Semisolid Full

1 3 2 0 1 0

1 13 3 2 5 3

1 23 1 3 7 12

2 1 0 0 1 0

5 40 6 5 14 15

Prior XRT indicates preoperative radiotherapy exposure; post-OP XRT, postoperative radiotherapy.

TABLE 2. Fistula and Stricture Formation Rate Fistula (8/45) Stricture (4/43)†

Patch

Near-Cir/Cir*

P

4 (8.9%) 3 (7.0%)

4 (8.9%) 1 (2.3%)

0.694 0.640

TABLE 5. Comparison of ALT Flap and Jejunal Flap

*Cir indicates circumferential. †Two patients with stricture were excluded because of recurrence.

ALT Flap

TABLE 3. Radiation Effect on Stricture and Fistula Prior XRT (+)

Prior XRT (j)

Post-OP XRT Yes (n = 4) No (n = 14) Yes (n = 24) No (n = 3) Total Stricture Fistula

0 2

2 3

1 3

1 0

4 8

Prior XRT indicates preoperative radiotherapy exposure; post-OP XRT, postoperative radiotherapy.

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Donor-site morbidity

Minor

Fistula rate3,6,20 Fistula healing time7,23 Delaying CCRT treatment24 Stricture rate4,6,24 Oral diet1,4,6,12,14 Learning curve effect Contraindication

7%Y18% Quicker Less

Need other flap

5%Y15% 69%Y91% Minor Major systemic disease None

Free Jejunal Flap Major (ileus, hernia, bowel obstruction, internal bleeding) 3.2%Y22% Slower More 2.3%Y22% 59%Y88% Major Previous intra-abdomenal operation Pectoralis major myocutaneous flap Deltopectoral flap

ALT indicates anterolateral thigh; CCRT, concurrent chemoradiotherapy.

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abusers at high risk of chronic obstructive pulmonary disease, meaning abdominal surgery readily contributes to major complications, for example, adhesion, bowel obstruction, internal bleeding, hernia, and wound dehiscence.12,13,16,20 The major complication rate ranged from 5.8% to 25%4,21,22; some authors prophylactically used pectoralis major muscle f lap, hence adding 1 more donor-site complication.15 Any of the above may inevitably lengthen hospital and intensive care unit stay more than that with ALT f lap reconstruction.23 Mean (SD) hospital stay was 24 (10) days (range, 13Y64 d), longer than that given in other articles; most head and neck cancer cases in our series were at advanced stages.6 Minimal donor-site complication was noted in ALT f lap. Donor-site wounds were closed primarily in 89% of our patients, without donor-site complication. As therapeutic challenges faced by most plastic surgeons, 89% of patients with hypopharyngeal cancer were diagnosed at an advanced stage.3 Anterolateral thigh flap reconstruction is a 1-stage procedure,

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with high, spontaneous, early closure rate of fistula, offering patients adjuvant radiotherapy therapy without delay.5,13 Musculocutaneous flaps also have advantages of a more tolerable radiation dosage, so some reports revealed that ALT flap may have a better locoregional control rate in stage IV hypopharyngeal cancer.24 In our hospital, the reconstructive method was selected based on characteristics including stage of cancer, area of cancer, postoperative voice selected by patient, and major systemic disease (Fig. 7). Speech function is vital to hypopharyngeal reconstruction. Our case series adopted pneumatic artificial larynx for every patient. The pneumatic artificial larynx is a popular device commonly used in Taiwan by virtue of its cost-effectiveness and ability to intone words in local languages.25 After hypopharyngeal reconstruction, patients could communicate without difficulty. The trapezoid design method not only provided a simplified surgical procedure but also made postoperative nursing care easier. After surgery, nurses observed the

FIGURE 7. Reconstructive algorithm of pharyngoesophageal defect. 178

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monitoring window of the VL muscle, which was pulled out with ease; it would finally shrink and then heal without further surgical closure. Our study had limitations. Body mass index was not available in records; we could ascertain whether a morbidly obese patient was enrolled. In overweight patients, the ALT f lap may not be suitable because of the thick skin f lap. Clinical judgment to determine the cutoff on body mass index or f lap thickness is still not well defined.1,6 On the other hand, only 2 surgeons performed ALT f lap reconstruction in this series. Operator effects could not be excluded, yet it may be derived from our trapezoid ALT f lap as it is relatively simplified and showed potential as a widely adapted procedure, without a long learning curve.

CONCLUSIONS Anterolateral thigh f lap affords good coverage and swallowing function in the reconstruction of a hypopharyngeal defect, with minimal donor-site complication. Trapezoid ALT flap simplifies the design, with a low complication rate. REFERENCES 1. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer. 2010;116:1718Y1724. 2. Andrades P, Pehler SF, Baranano CF, et al. Fistula analysis after radial forearm free flap reconstruction of hypopharyngeal defects. Laryngoscope. 2008;118: 1157Y1163. 3. Richmon JD, Brumund KT. Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg. 2007;15:208Y212. 4. Yu P, Lewin JS, Reece GP, et al. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg. 2006;117:968Y974. 5. Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg. 2005;116: 1845Y1855. 6. Spyropoulou GA, Lin PY, Chien CY, et al. Reconstruction of the hypopharynx with the anterolateral thigh flap: defect classification, method, tips, and outcomes. Plast Reconstr Surg. 2011;127:161Y172. 7. Chang DW, Hussussian C, Lewin JS, et al. Analysis of pharyngocutaneous fistula following free jejunal transfer for total laryngopharyngectomy. Plast Reconstr Surg. 2002;109:1522Y1527. 8. Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial forearm flap. Clin Plast Surg. 1994;21:137Y147.

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9. Azizzadeh B, Yafai S, Rawnsley JD, et al. Radial forearm free flap pharyngoesophageal reconstruction. Laryngoscope. 2001;111:807Y810. 10. Cho BC, Kim M, Lee JH, et al. Pharyngoesophageal reconstruction with a tubed free radial forearm flap. J Reconstr Microsurg. 1998;14:535Y540. 11. Scharpf J, Esclamado RM. Reconstruction with radial forearm flaps after ablative surgery for hypopharyngeal cancer. Head Neck. 2003;25:261Y266. 12. Reece GP. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg. 1995;96:1307. 13. Cordeiro PG, Shah K, Santamaria E, et al. Barium swallows after free jejunal transfer: should they be performed routinely? Plast Reconstr Surg. 1999;103: 1167Y1175. 14. Disa JJ, Pusic AL, Hidalgo DA, et al. Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast Reconstr Surg. 2003;111: 652Y660; discussion 661Y663. 15. Moradi P, Glass GE, Atherton DD, et al. Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience from a single reconstructive center. Plast Reconstr Surg. 2010;126:1960Y1966. 16. Schusterman MA, Shestak K, de Vries EJ, et al. Reconstruction of the cervical esophagus: free jejunal transfer versus gastric pull-up. Plast Reconstr Surg. 1990;85:16Y21. 17. Lewin JS, Barringer DA, May AH, et al. Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction. Head Neck. 2006;28: 142Y149. 18. Weinrach JC, Cronin ED, Smith BK, et al. Preventing seroma in the latissimus dorsi flap donor site with fibrin sealant. Ann Plast Surg. 2004;53:12Y16. 19. Gosain AK, Lyon VB. The current status of tissue glues: part II. For adhesion of soft tissues. Plast Reconstr Surg. 2002;110:1581Y1584. 20. Murray DJ, Gilbert RW, Vesely MJ, et al. Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube. Head Neck. 2007;29: 147Y154. 21. Shangold LM, Urken ML, Lawson W. Jejunal transplantation for pharyngoesophageal reconstruction. Otolaryngol Clin North Am. 1991;24: 1321Y1342. 22. Bradford CR, Esclamado RM, Carroll WR, et al. Analysis of recurrence, complications, and functional results with free jejunal flaps. Head Neck. 1994;16: 149Y154. 23. Murray DJ, Novak CB, Neligan PC. Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg. 2008;61:1148Y1156. 24. Chan JY, Chow VL, Chan RC, et al. Oncological outcome after free jejunal flap reconstruction for carcinoma of the hypopharynx. Eur Arch Otorhinolaryngol. 2012;269:1827Y1832. 25. Chen HC, Kim Evans KF, Salgado CJ, et al. Methods of voice reconstruction. Semin Plast Surg. 2010;24:227Y232.

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Functional Outcome Analysis After Anterolateral Thigh Flap Reconstruction of Pharyngoesophageal Defect.

Pharyngoesophageal defects are traditionally reconstructed with jejunal or radial forearm flaps. Recently, anterolateral thigh flaps have served for p...
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