Prefabricated and Prelaminated Forearm Flaps for Larynx and Trachea Reconstruction

The current surgical treatment for unilateral, advanced, glottic cancer is a total laryngectomy. Tracheal autotransplantation by prefabrication with a custom radial forearm fascia flap allows for reconstruction of extended hemi-laryngectomy defects. The technique involves a two-stage procedure. After the neck and tumor resection, a 4-cm cervical trachea segment is wrapped with a radial forearm fascia flap that is designed with a proximal skin paddle which is used for temporary closure of the extended defect and serves as a monitor island after microvascular anastomoses in the neck. In 2 weeks, this trachea segment is revascularized. In a second stage, after the hemi-laryngectomy, the prefabricated vascularized trachea segment is completely isolated from the airway and transformed into a patch which is sutured to the laryngeal defect.

A series of 40 patients underwent the operation. After the first stage, the skin paddle of the flap restored the sphincter function. The mean time to oral intake for solids was 9.0 days (SD = 2.6 d) and the mean length of hospital stay was 11.2 days (SD = 2.2 d). All patients were able to speak with the tracheal cannula in place. All laryngeal functions were restored after the second operation. The mean time to oral intake for solids was 8.2 days (SD = 5.2 d). The mean time to oral intake for liquids was 16.6 days (SD = 6.3 d), and the mean length of hospital stay was 9.6 days (SD = 2.3 d). The mean time to closure of the tracheostomy and removal of the gastric tube was 27.0 days (SD = 5.8 d).

For long-segment tracheal stenosis and re-stenosis after tracheal resection, well-vascularized tissue is required that restores internal lining and gives structural support, in order to resemble native tracheal tissue as closely as possible.

The authors use a radial forearm fascia flap prelaminated with strips of autologous ear cartilage and buccal mucosa. After 3 weeks, the oral mucosa grows over the cartilage grafts. Heterotopic prefabrication of the composite tissue is essential for survival of the cartilaginous component, but a prelaminated ‘buccal-mucosa-free fascia flap’ allows for a one-stage procedure. Significant additional airway lumen expansion could be obtained after heterotopic flap prelamination and prefabrication.