Abstract
Complex tracheal and laryngeal defects can be reconstructed using prelamination and
prefabrication techniques. Three clinical situations are described in detail in the
article. In short segment restenosis defects within scarred surroundings, we restore
the fibrocartilaginous defect with a radial forearm fascia flap prelaminated with
buccal mucosa or cartilage. This provides a newly vascularized inner lining to the
tracheal defect and restores the tubular convexity. For long segment defects we need
a technique that can withstand respiratory forces. We use a heterotopic prefabrication
strategy to vascularize a tracheal allograft wrapped in forearm fascia. Chimerism
is created by replacing donor respiratory epithelium with buccal mucosa of the recipient.
After orthotopic transfer, this chimerism allows immunosuppression to be tapered and
stopped when bronchoscopy shows mucosal integrity of the new trachea, since the recipient
epithelium replaces the allogeneic inner tracheal lining by means of a chronic rejection
process. A distinct situation occurs after resection of a unilateral larynx tumor,
which usually results in a total laryngectomy with loss of both vocal cords, since
reconstruction of the hemilarynx is considered too complex. First, we prefabricate
a nearby four-ring autologous tracheal segment using radial forearm fascia. In a second
stage, this orthotopically vascularized trachea restores the laryngeal structure with
the aim to conserve one vocal cord and thus speech. Orthotopic and heterotopic prelamination
and prefabrication strategies offer efficient and reproducible solutions for the restoration
of challenging short and long segment tracheal defects, as well as unilateral laryngeal
defects. The series in this review article are based on previous studies and case
reports. The level of evidence is III—“Study of nonconsecutive patients, without a
universally applied gold standard: case-control study”.
Keywords
prefabrication - prelamination - trachea reconstruction - larynx reconstruction -
trachea transplantation
