The Paddle Flap: A New Flap Design for Cervical Esophageal Reconstruction

Reconstruction of the cervical esophagus and pharynx can be especially challenging in patients with prior irradiation, recurrent disease, or compromised or deficient overlying neck skin.

The authors reported their experience with seven patients who underwent cervical esophageal reconstruction with a new flap design that addresses both concerns of monitoring the internal skin tube and replacing the external neck skin with one flap. This design has two skin islands, one that is tubed and the other left flat. The tubed portion resembles the “handle” of a paddle that is used for esophageal reconstruction and the cutaneous paddle is then folded over the “handle” to provide external skin. The external skin portion of the flap not only provides an external monitoring segment but releases tension on the neck apron incision and may replace compromised native neck skin. The length of esophageal defects ranged from 4 to 11 cm and the anterior cervical skin requirements ranged from 4 × 2 cm to 10 × 12 cm.

The authors designed the paddle flap with five radial forearm flaps and two anterolateral thigh flaps. Follow-up has been between 18 months and 4 years. There were no partial or complete flap losses. All patients are currently tolerating an oral diet. There was one case of partial donor-site skin graft loss which was treated with re-grafting. There were two cases of stricture formation which were treated successfully with neo-esophageal dilation.

A new simple, versatile design of a cutaneous free flap has been developed that addresses both concerns of monitoring the internal skin tube and dealing with compromised overlying skin in patients undergoing cervical esophageal reconstruction. The paddle flap design can be utilized with any thin cutaneous free flap and may offer an advantage when an external monitor is desired and anterior neck skin requires supplementation or replacement.