Reconstruction of phonatory function using a tubular free flap from upper-lateral upper arm after near-total laryngectomy_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Liu , ZHENG Yitao ,  LI Wen

Department of Otolaryngology Head and Neck Surgery, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P. R. China;

Corresponding author：

LI Wen, Email: church.ent.wc@163.com

Keywords：

Laryngeal cancer; near-total laryngectomy; free flap; upper arm flap; phonatory reconstruction

DOI：

10.7507/1002-1892.202411048

Video：

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Objective To explore the feasibility of reconstruction of phonatory function by using a tubular free flap from upper-lateral upper arm to repair the laryngotracheal circumferential defect after near-total laryngectomy for laryngeal cancer. Methods A retrospective study was conducted on 7 patients who underwent near total laryngectomy between June 2021 and October 2023, aged from 48 to 70 years, 6 males and 1 female, with a median age of 59 years. The disease duration ranged from 1 to 11 months, with a median of 6 months. Pathological diagnosis of preoperative biopsy was squamous cell carcinoma. Tumor classification: glottic type in 5 cases, supraglottic type in 1 case, transglottic type in 1 case; TNM staging: T₄N₀M₀ in 6 cases, T₄N₂M₀ in 1 case; American Joint Committee on Cancer (AJCC) staging in 2017 was stage Ⅳ. Preoperative MRI angiography of upper arm was performed to investigate the blood supply in the upper and lateral regions of the upper arm. After near-total laryngectomy and bilateral neck lymph node dissection, the area of the laryngotracheal defect was measured. A free flap measuring 7.0 cm×5.0 cm to 8.0 cm×7.0 cm was harvested from the upper-lateral upper arm, rolled into a tube shape, and connected between the stump of the cervical trachea in the neck root and that of the epiglottis at the tongue base. Four patients received adjuvant radiochemotherapy, 1 patient received radiochemotherapy and targeted therapy, 2 patients adopted no further adjuvant treatment. Resutls All 7 patients were followed-up 1-2 years (mean, 1 year and 3 months). Four patients had primary wound healing, 2 patients had minor pharyngeal fistulas that healed after dressing change, 1 patient experienced pharyngeal fistula because of flap loss and the wound still healed without secondary surgery. All patients took food orally within 1 month after operation, and the tracheal cannula was retained. Six patients with survived flap gradually adapted to their new pronunciation mode and obtained satisfactory phonatory function from 15 days to 2 months after operation. Four patients had slight aspiration after operation. Till the end of the follow-up, all patients survived and no local recurrence or distant metastasis had been observed. The tracheostomy tubes of all patients were not withdrawn. The motor function of the upper arm of the patient was not affected, only partial sensory loss occurred in the area near the incision . The scar of the incision could be covered by the short sleeve so as to obtain a better aesthetic effect. Conclusion Using a tubular free flap from upper-lateral upper arm to repair the laryngotracheal circumferential defect after near-total laryngectomy for laryngeal cancer can achieve satisfactory phonatory restoration while preserve the motor function and aesthetics of the donor site in selected cases.

1.	Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg, 1994, 120(6): 633-640.
2.	Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin Plast Surg, 1982, 9(1): 27-35.
3.	Gellrich NC, Kwon TG, Lauer G, et al. The lateral upper arm free flap for intraoral reconstruction. Int J Oral Max Surg, 2000, 29(2): 104-11.
4.	袁冶, 陶震江, 吴煜农, 等. 上臂外侧皮瓣在口腔癌术后缺损修复中的初步应用. 中华口腔医学杂志, 2006, 41(10): 593-595.
5.	李赞, 喻建军, 黄文孝, 等. 游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用. 组织工程与重建外科杂志, 2007, 3(2): 83-85.
6.	孙瑞梅, 王金德, 李群, 等. 改良游离上臂外侧皮瓣应用解剖研究. 中华耳鼻咽喉头颈外科杂志, 2013, 48(1): 37-41.
7.	Wang WM, Sun L, Yang SS, et al. Comparison between modified lateral arm free flap and traditional lateral arm free flap for the reconstruction of oral and maxillofacial Soft tissue defects. Front Oncol, 2022, 12: 877799. doi: 10.3389/fonc.2022.877799.
8.	Contrera KJ, Hassan AM, Shuck JW, et al. Outcomes for 160 consecutive lateral arm free flaps for head and neck reconstruction. Otolaryngol Head Neck Surg, 2024, 170(3): 747-757.
9.	李超, 蔡永聪, 王薇, 等. 游离上臂外侧皮瓣在头颈肿瘤术后修复重建中的角色定位. 中华耳鼻咽喉头颈外科杂志, 2016, 51(2): 156-160.
10.	高建华, 罗力生, 陈林峰, 等. 上臂五种游离皮瓣的临床应用及其评价. 中华整形烧伤外科杂志, 1989, 5(2): 89-90, 156.
11.	Yoshimatsu H, Karakawa R, Fuse Y, et al. The use of the deep brachial artery as the recipient artery for free perforator flap transfer: An anatomic study and clinical applications. Medicina (Kaunas), 2023, 59(6): 1087. doi: 10.3390/medicina59061087.
12.	杨柳, 李文, 郑义涛, 等. 股前内侧皮瓣修复晚期喉癌保留舌骨上部分会厌的近全喉切除后环周缺损. 中国修复重建外科杂志, 2024, 38(2): 133-139.
13.	Marques Faria JC, Rodrigues ML, Scopel GP, et al. The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases. J Plast Reconstr Aesthet Surg, 2008, 61(2): 172-179.
14.	Amin JD, Amin N, Hatten KM. The lateral arm free flap for head and neck reconstruction. Curr Opin Otolaryngol, 2020, 28(5): 365-369.
15.	de la Parra Marquez M, Fernandez-Riera R. Medial arm flap: An unexplored option for autologous breast reconstruction in the setting of morbid obesity. Ann Plast Surg, 2019, 82(2): 190-192.
16.	Meltem A, Metin G, Zeynep A, et al. The free deltoid flap: clinical applications to upper extremity, lower extremity, and maxillary defects. Microsurgery, 2007, 27(5): 420-424.
17.	Tweel M, Dow T, Greene B, et al. Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review. J Plast Reconstr Aesthet Surg, 2024, 92: 130-144.

1. Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg, 1994, 120(6): 633-640.
2. Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin Plast Surg, 1982, 9(1): 27-35.
3. Gellrich NC, Kwon TG, Lauer G, et al. The lateral upper arm free flap for intraoral reconstruction. Int J Oral Max Surg, 2000, 29(2): 104-11.
4. 袁冶, 陶震江, 吴煜农, 等. 上臂外侧皮瓣在口腔癌术后缺损修复中的初步应用. 中华口腔医学杂志, 2006, 41(10): 593-595.
5. 李赞, 喻建军, 黄文孝, 等. 游离上臂外侧皮瓣在头颈肿瘤术后缺损修复的临床应用. 组织工程与重建外科杂志, 2007, 3(2): 83-85.
6. 孙瑞梅, 王金德, 李群, 等. 改良游离上臂外侧皮瓣应用解剖研究. 中华耳鼻咽喉头颈外科杂志, 2013, 48(1): 37-41.
7. Wang WM, Sun L, Yang SS, et al. Comparison between modified lateral arm free flap and traditional lateral arm free flap for the reconstruction of oral and maxillofacial Soft tissue defects. Front Oncol, 2022, 12: 877799. doi: 10.3389/fonc.2022.877799.
8. Contrera KJ, Hassan AM, Shuck JW, et al. Outcomes for 160 consecutive lateral arm free flaps for head and neck reconstruction. Otolaryngol Head Neck Surg, 2024, 170(3): 747-757.
9. 李超, 蔡永聪, 王薇, 等. 游离上臂外侧皮瓣在头颈肿瘤术后修复重建中的角色定位. 中华耳鼻咽喉头颈外科杂志, 2016, 51(2): 156-160.
10. 高建华, 罗力生, 陈林峰, 等. 上臂五种游离皮瓣的临床应用及其评价. 中华整形烧伤外科杂志, 1989, 5(2): 89-90, 156.
11. Yoshimatsu H, Karakawa R, Fuse Y, et al. The use of the deep brachial artery as the recipient artery for free perforator flap transfer: An anatomic study and clinical applications. Medicina (Kaunas), 2023, 59(6): 1087. doi: 10.3390/medicina59061087.
12. 杨柳, 李文, 郑义涛, 等. 股前内侧皮瓣修复晚期喉癌保留舌骨上部分会厌的近全喉切除后环周缺损. 中国修复重建外科杂志, 2024, 38(2): 133-139.
13. Marques Faria JC, Rodrigues ML, Scopel GP, et al. The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases. J Plast Reconstr Aesthet Surg, 2008, 61(2): 172-179.
14. Amin JD, Amin N, Hatten KM. The lateral arm free flap for head and neck reconstruction. Curr Opin Otolaryngol, 2020, 28(5): 365-369.
15. de la Parra Marquez M, Fernandez-Riera R. Medial arm flap: An unexplored option for autologous breast reconstruction in the setting of morbid obesity. Ann Plast Surg, 2019, 82(2): 190-192.
16. Meltem A, Metin G, Zeynep A, et al. The free deltoid flap: clinical applications to upper extremity, lower extremity, and maxillary defects. Microsurgery, 2007, 27(5): 420-424.
17. Tweel M, Dow T, Greene B, et al. Anatomy, surgical techniques, and clinical outcomes for the medial arm flap: A systematic review. J Plast Reconstr Aesthet Surg, 2024, 92: 130-144.

Chinese Journal of Reparative and Reconstructive Surgery

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