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The supraclavicular artery island flap (SCAIF) is a thin and pliable pedicled flap that is easy and quick to harvest. Thanks to its particular features and high reliability, it is best indicated for the elderly or most fragile patients. SCAIF is very versatile, as it can be used for reconstruction of oral cavity, oropharynx, hypopharynx, facial and cervical skin and tracheostomal defects. We began using this flap in four Italian tertiary referral centres, with several indications, both as first treatment and as salvage surgery. The aim of the study was to demonstrate the easy reproducibility of the flap among four different centres. A series of 28 patients underwent head and neck reconstructions with SCAIF with no recorded complications during flap harvesting. After the very first cases, harvesting time was approximately 45 minutes; 24 patients had successful flap integration at the recipient site, while the remaining 4 suffered from partial flap necrosis, two of whom needed revision surgery. Other minor complications were reported at the recipient site, always at the most distal and most delicate portion of the flap. Donor site was always closed primarily, with only three cases of partial suture dehiscence. We only selected the most fragile patients for SCAIF reconstruction, such as the elderly or those with one or more comorbidities; for this reason, we reported some serious systemic complications and one intraoperative death. SCAIF is an easy reproducible flap, with multiple possible indications. Its use as an alternative to free flaps in the head and neck region is nowadays under discussion. Its use should be encouraged among head and neck surgeons thanks to its various advantages., (Copyright © 2018 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Over the last 20 years, free flaps have represented the gold standard for moderate to large head and neck reconstruction. However, regional flaps continue to evolve and still play an important role in a reconstructive surgeon's armamentarium, especially for the more delicate patients who would certainly benefit from simpler surgical procedures. The supraclavicular artery island flap (SCAIF) is a pedicled flap that has recently gained great popularity for reconstruction of most head and neck sites, because of its unusual versatility and wide arc of rotation. SCAIF is a fasciocutaneous flap that is very reliable and both easy and quick to harvest. It is pedicled on the supraclavicular artery, which is a branch of the transverse cervical artery. Between October 2012 and July 2015, at Ospedale San Raffaele (Milan, Italy) and Policlinico San Matteo (Pavia, Italy), we used the SCAIF procedure on 14 patients with cervical and facial skin, oral cavity, oropharyngeal, and hypopharyngeal defects after oncologic surgery or as revision surgery after free-flap failure. The presence of the supraclavicular artery was demonstrated preoperatively by computed tomography angiography. Harvesting time never exceeded 50 min. Functional outcomes were excellent, and the donor site was always closed. We reported only one case of tip desquamation, which was treated conservatively, and two cases of partial flap necrosis, which required revision surgery. In our opinion, SCAIF should be considered to be a valid alternative to free-flap reconstruction, especially for facial and cervical skin, floor-of-mouth, and hypopharyngeal defects; oropharyngeal defects may be harder to reconstruct.

The present retrospective analysis evaluated the outcomes of different flap reconstructions for several hypopharyngeal defects in 136 patients who underwent hypopharyngeal reconstruction with a free or pedicled flap after excision of pharyngeal or laryngeal carcinoma.Functional and oncological outcome were the main measures. Nine patients had a type I-a hypopharyngeal defect (partial with larynx preserved), 33 type I-b (partial without larynx preserved), 85 type II (circumferential), 5 type III (extensive superior) and 4 vertical hemipharyngolaryngectomy. The flaps used to reconstruct these defects were pectoralis major (n = 34), free radial forearm (n = 25), jejunum (n = 72), pedicled latissimus dorsi (n = 2), sternocleidomastoid (n = 1), lateral thigh (n = 1) and deltopectoral (n = 1). Twelve defects (9%) needed a secondary flap reconstruction. Surgical and medical complications were seen in 29% and 8% of patients, respectively; 18% of patients developed a fistula. No difference in complication rate or admission days was found for pre-operative versus no previous radiotherapy, type of defect or free versus pedicled flap. After 12 months follow-up, 38% of patients had a tracheo-oesophageal voice prosthesis, in 82% a fully oral diet was obtained and the average body weight gain was 0.9 kg. Five-year overall and disease-specific survival rates were 35% and 49%, respectively, while local and regional control rates were 65% and 91%, respectively. Considering these results, a defect orientated approach may be helpful for deciding which flap should be used for reconstruction of the hypopharynx. An algorithm is proposed with similar functional and oncological outcomes for the different groups. The choice of flap should be based on expected morbidity and functional outcome.

Study Design: A retrospective report was conducted on clinical and instrumental data of 3 patients treated for esophageal perforation after anterior cervical spine surgery., Objective: To define indications and evaluate the safety and effectiveness of surgical repair of esophageal perforations by means of sternocleidomastoid (SCM) muscle flap in the setting of anterior spinal surgery., Summary of Background Data: Esophageal perforation is an occasional or underreported complication in anterior cervical spine surgery. To prevent its potentially devastating and even life-threatening sequelae, prompt diagnosis and treatment are required. No treatment protocol has yet been standardized. In addition to conservative measures, several surgical approaches have been presented, ranging from primary repair to reconstruction with local, regional, or distant flaps., Methods: Primary spinal pathology and intervention, esophageal fistulae morphology, diagnostic work-up, clinical course, and surgical techniques for their repair are illustrated in each case. Follow-up data have been gathered by in-person visits., Results: Mean time from discovery of perforation to definitive surgical treatment institution was 44.3 days (range: 34 to 61 d). SCM muscle flap way used as reinforcement and protection of a primary esophageal suture in 2 cases and as a patch to the perforation in 1 case. All the fistulae healed without further complications. Mean time to oral feeding resumption was 17.6 days (range: 10 to 27 d) and mean hospitalization time was 19 days (range: 11 to 28 d). All the patients presented with a free oral diet at the last follow-up check., Conclusions: Esophageal perforation treatment has to be multidisciplinary and tailored on each individual case. SCM muscle flap, used as reinforcement of a primary suture or as a patch to the lesion, has proved to be effective as definitive treatment for persisting or recurring esophageal fistulae after anterior cervical spine surgery. In this setting, conservative treatments may be inadequate or may actually perpetuate the condition.

Reconstruction after circumferential pharyngolaryngectomy is a challenging problem. Reconstruction methods should ensure an appropriate mucosa lining of the digestive tract, preferably already tubulized, and peristalsis. Despite the high reported success rates, the jejunum flap is still occasionally lost due to thrombosis of the pedicle and/or fistula formation. Five cases of circumferential pharyngolaryngectomy in which failure of the jejunum loop was managed with a second free or pedicle flap are presented. A second free jejunum was reliable in selected patients, depending on time of detection of flap necrosis, on bacterial control of the wound and on the vascular or general conditions. For this reason, careful monitoring of the flap and clinical signs of necrosis in the first 5 post-operative days is crucial to prevent the formation of fistulas and infection and to increase the possibility of using this kind of salvage surgery. Pedicle flaps should be used only in the event of severe complications because of their high risk of post-operative salivary fistulas.

The ideal reconstruction after circumferential pharyngolaryngectomy is represented by the jejunum free flap, but when the resection extends to the oro- or nasopharynx, the discrepancy between the lumen of the flap and the pharyngeal defect represents a disadvantage. Two reconstructions to overcome this problem are presented: end-to-side anastomosis between the pharynx and the antimesenteric side of the jejunum; and a jejunal "reservoir." The type 1 technique is quicker to perform, but can result in dysphagia; the type 2 technique is more complex, but usually no dysphagia is observed. In our opinion, no ideal surgical technique exists to equal the jejunum loop. The choice must be tailored to the single patient, bearing in mind the degree of the defect, the stage of the tumor removed, the general conditions of the patient, and personal surgical experience. Whatever procedure is chosen, it should provide the best possible quality of life for the expected life span of the patient., ((c) 2007 Wiley-Liss, Inc.)

Following oncologic surgery for advanced cancer of the hypopharynx, primary closure of the defect of the upper aerodigestive tract is difficult to achieve. Usually locoregional or free flaps are used, the choice being determined by the extent of the surgical defect, the expertise of the surgeons and the general condition of the patient. Aim of the present study was to evaluate the functional recovery of patients who underwent surgical reconstruction, following hypopharyngeal cancer resection, with pedicled or free flaps. A retrospective analysis was conducted examining hospital records of the patients submitted to surgical treatment for hypopharyngeal cancer and reconstruction with pedicled or free flaps in the period between January 1995 and July 2004. Free flaps showed less severe complications, shorter hospital stay, less time to resume oral feeding compared with pedicled flaps. For this reason, we consider free flaps the gold standard for hypopharyngeal reconstruction, while pedicled flaps as the pectoralis major or other locoregional flaps should be used in those cases in which free flap reconstruction is not feasible or contraindicated.

The jejunal free flap is a standard technique in the reconstruction of hypopharyngeal and cervical esophageal defects. Conventional harvesting of the jejunal segment is performed with midline open laparotomy, which is associated with complications including prolonged ileus, abdominal pain, wound infection or dehiscence. Laparoscopic resection of the small intestine is a well documented surgical technique. Two different methods of laparoscopic harvest of a jejunal autografts for their cervical implantation have been already described. In both cases, low complication rate and better postoperative course have been observed in the patients treated. During the last 10 years, we have performed 43 circumferential pharyngoesophageal resection for advanced hypo-pharyngeal cancer followed by reconstruction with a free flap of jejunum. All but one the jejunal segments have been harvested with conventional open laparotomy. In the last patient of this group, laparoscopic harvest of the jejunal segment has been successfully performed. In this paper, we describe the laparoscopic technique used and we compare the postoperative course of this patient with those of the patients treated with conventional technique.

The objective of the study was to compare the rate of complications and the functional outcomes following reconstructive surgery with pedicled and free flaps for recurrences after laryngeal cancer treatment. A retrospective analysis was conducted among the clinical records of the Department of Otolaryngology Head Neck Surgery of the University of Pavia from January 1995 to December 2004. Twenty-three patients were identified as having been reconstructed with pedicled or free flaps for hypopharyngeal recurrences after laryngeal cancer treatment. We observed a higher rate of postoperative complications after pedicled flaps (60%) than free flaps reconstructions (23%). The pedicled flaps group evidenced a longer hospitalization time (35 versus 14 days); a lower rate of patients with pedicled flaps (14% versus 69%) was able to resume a normal feeding 1 year after surgery; no patient achieved an esophageal voice, but the entire free flaps group reached an intelligible voice with the positioning of a voice prosthesis. The possibility to achieve such functional results in this kind of patient justifies the use of a surgical approach that generally requires a longer operation time than pedicled flaps, and the need for a surgical team with special skills in microsurgical techniques.

Background: Surgical treatment of hypopharyngeal cancers with extension to the retrocricoid region generally requires a circumferential pharyngolaryngectomy followed by a reconstruction of the removed segment of the upper digestive tract. Historically, many techniques have been used in order to achieve a safe and functional reconstruction. Jejunum interposition is generally considered the best reconstructive technique., Methods: This study examines the details of the surgical technique, the complications, the oncological and the functional results in a series of 29 consecutive patients submitted to circumferential pharyngoesophageal resection for advanced hypopharyngeal cancer followed by reconstruction with a free flap of jejunum., Results: Three of the transplants failed because of venous thrombosis. The overall success rate was 90%. There were no general complications. A good swallowing has been preserved in all our patients. All our patients where a phonatory prosthesis was positioned (20/29) were able to achieve speech following speech therapy and all were satisfied with their own capacity to communicate., Conclusions: The prognosis of hypopharyngeal tumours (18-40% at 5 years) remains poor, but jejunum autografts are being shown to be an excellent choice for the reconstruction of the cervical hypopharyngo-oesophagus offering the patient fast rehabilitation and a reasonable quality of survival. Our experience confirm that this kind of reconstruction is safe with a good results in improving oncologic controls and restoring a good quality of life.

In the authors' series of 12 consecutive patients who had oral reconstruction using the indications described above, flap survival always was achieved. Venous congestion was observed often: the flap became intensively red, showing a disappointing color that resolved spontaneously with only skin de-epithelialization. In one case of floor-of-the-mouth repair, a marginal necrosis of the distal portion of the flap occurred, possibly because of a venous drainage problem. The secondary defect healed spontaneously, without fistula formation. The time required to outline the flap is less than for most other flaps, and donor site morbidity is minimal. In selected cases, a platysma flap is an easy and rewarding solution for repairing various oral defects.

The gastric pull-up or pharyngogastroplasty is the most widely used technique in reconstructing the digestive tract in cases of distal oesophageal tumours. This operation consists of drawing the stomach or part of it up through the chest and mediastinic region to the neck where a mucosal anastomosis with the residual pharyngeal tract is made. The most feared complication is proximal necrosis of the gastric stump with salivary fistulae usually followed by a mediastinitis. In the presence of such a complication the surgeon must tackle the challenge of reconstructing the missing part of the intrathoracic digestive tract. We describe the case of a patient in whom the missing intrathoracic oesophagus, following complete necrosis of a previously performed pharyngogastroplasty, was reconstructed using a revascularized lateral thigh free flap.

The aggressiveness of hypopharyngeal cancer makes broad resectioning of the circular pharyngolaryngoesophageal segments necessary, followed by reconstruction to restore the anatomical gap created as fully as possibly creating a neoesophagus with thin walls that can easily be released. Over the years several procedures have been fine tuned for reconstruction of the upper digestive tract employing transposed viscera, miocutaneous pedunculated flaps, revascularized fascio-cutaneous or visceral free flaps. Currently the revascularized jejunum loop is one of the most commonly used methods in the reconstruction of the hypopharynx. Its popularity is due to some anatomical and physiological advantages: it requires transposition of a brief intestinal tract anatomically well adapted to the reconstruction site, ensuring rapid functional recovery. The authors report the oncological and functional results obtained in 25 patients who underwent circular pharyngolaryngectomy followed by reconstruction with a revascularized jejunum loop. The percentage of transplant survival was 90% and local and general complications were reduced to a minimum. The functional results--both in terms of deglutition and phonation--were satisfactory while patient survival (6-37 months follow-up) was in line with that reported by other authors for the same tumor (47%). Although prognosis for hypopharyngeal-esophageal neoplasms is still quite poor, this experience shows that circular pharyngolaryngectomy followed by reconstruction with autotransplant of the jejunum is an excellent choice since it offers the patient a prompt, acceptable functional recovery and a fair quality for his remaining life.

Objective: To investigate the capacity of helical CT in the pre- and post-operative management of oromandibular reconstruction of patients with oropharyngeal carcinoma using microvascular composite free flaps., Materials/methods: Thirty-four patients with oropharyngeal cancer were examined by helical CT and nine (six men and three women) submitted to oromandibular reconstruction. The osteomyocutaneous flaps used for reconstruction were taken from the iliac crest in six cases and from the fibula in three cases. All patients were examined by CT 1 - 4 days postoperatively and then at 6 monthly intervals. Double helical scans were performed in all cases, with slices of 2 - 3 mm for primary lesion studies and 5 mm for lymph node staging, pitch >/=1 and RI=1. Multiplanar (MPR) and 3D reconstructions were obtained from pre- and postoperative CT examinations., Results: Preoperative CT showed massive bone infiltration in six of the nine surgical patients and marginal infiltration in three. These findings were confirmed histologically. There were no false negatives. The immediate postoperative examination showed correct flap positioning in eight of nine cases. The flap underwent ischemic necrosis in two cases; CT showed very early signs of bone ischemia in both. CT detected two cases of recurrence after about 1 year., Conclusions: Axial CT permitted adequate assessment of the extent of mandibular infiltration and detected early ischemic complications and distant recurrences. Integration with MPR and 3D reconstructions simplified the choice of flap type and size and enabled the postoperative assessment of correct flap positioning. This helped the surgeon plan subsequent rehabilitation with osseo-integrated implants.