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\begin{document}

\title{Scapular Free Flap Reconstruction of Pharyngoesophageal defects}



\author[1]{Shaum Sridharan}%
\author[1]{Vaibhav Ramprasad}%
\author[2]{Robert Keller}%
\author[2]{Terry Day}%
\author[2]{Eric J. Lentsch}%
\author[2]{Judith Skoner}%
\affil[1]{University of Pittsburgh Medical Center}%
\affil[2]{Medical University of South Carolina}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
* Scapular and parascapular free tissue transfer (SFTT) is a well
described reconstructive option for the head and neck. Majority of
reported outcomes are of reconstruction of oromandibular and midface
defects. The aim was to describe one institution's experience with SFTT
for reconstruction of PE defects. * This study was a retrospective
review of patients undergoing SFTT for head and neck defects between
2009 and 2014 at a tertiary center. The cohort included patients
undergoing reconstruction of PE defects with at least 6 months follow
up. Seventeen patients (13 male and 4 female) met inclusion criteria.
Surgical outcomes, speech, voice outcomes, swallowing outcomes, enteral
feeding and tracheoesophageal puncture (TEP) usage were evaluated. * Two
of 17 patients developed pharyngocutaneous fistulas (PCF) as inpatients.
There was one major medical complication (pulmonary embolism) and 7
minor complications. Mean hospital length of stay was 15.7 days (SD
8.2). In post-operative setting, only one patient remained
PEG-dependent, 11 patients supplemented oral intake with PEG feeds and 5
patients took nutrition solely by mouth. Four patients utilized written
communication exclusively, 6 patients pursued TEP placement and 7
utilized electrolarynx. * The SFTT is a viable option for hypopharyngeal
reconstruction. All scapula free tissue transfers remained viable for
the duration of our review. Post-operative PCF rate were comparable to
that reported after laryngectomy.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Scapular/Parascapular free tissue transfer (SFTT) is a versatile tool in
head and neck reconstructive surgery. Free flaps based off the
subscapular system allow the surgeon to harvest a combination of soft
tissue, bone, and muscle with limited donor site morbidity. Blood supply
to the skin paddle is composed of skin perforators from the vascular
pedicle allowing safe manipulation and contouring during flap inset.

The majority studies pertaining to SFTT report outcomes of
reconstruction of oromandibular and midface
defects.\textsuperscript{1,2} Limited data has been published on
pharyngoesophageal(PE) reconstruction with many studies focusing on
radial forearm or anterolateral thigh free flap
reconstruction.\textsuperscript{3,4}

Complications from failed PE reconstruction can often be life
threatening and delay adjuvant cancer treatment. Patients who develop
pharyngocutaneous fistula (PCF) experience increased duration of
hospital stay, are prone to infection, and risk carotid blowout.
Moreover, many who develop fistula, have stricture and are gastrostomy
tube (G-tube) dependent. SFTT has the potential to limit these
complications due to abundant soft tissue and skin capable of
reconstructing circumferential defects. Fasciocutaneous (FC) SFTT can
also be designed to fill cervical skin defects and protect great
vessels.

The objective of this study is to describe our institution's experience
with SFTT for the reconstruction of PE deficits. This review will focus
on surgical outcomes of PE defect closure, donor site morbidity, and
speech and swallowing function.

\textbf{METHODS}

\textbf{Patients:}

A retrospective review was conducted of all patients undergoing SFTT for
PE defects, between 2009 and 2014. All reconstructive procedures were
performed by the senior author (JMS). Patients were included if they had
documented follow up for at least 6 months with speech and language
pathology (SLP) evaluation.

\textbf{Data Collection and statistical analysis:}

The following data elements were collected for each patient in the
cohort: basic demographics, social history, defect classification,
previous treatment, ablative procedure, donor site morbidity, salivary
bypass tube use, and functional outcomes. Skin paddle dimensions,
recipient blood vessels, and venous coupler sizing were collected.
Surgical outcomes and complications were documented from flap donor site
and reconstructive site. SLP data including voice outcomes, swallowing
outcomes, enteral feeding usage, and tracheoesophageal puncture (TEP)
usage were reviewed and descriptive statistics performed.

\textbf{RESULTS}

After review of a database of over 200 scapula free tissue transfer
reconstructions conducted by the senior author (JMS) at our institution,
17 were included in the study (Table 1). All patients were left with
total laryngopharyngectomy defects after ablation necessitating free
tissue transfer reconstruction. Eighty-eight percent had already
undergone primary chemoradiation (n=9) or radiation-alone (n=6).

All patients had a preoperative diagnosis of squamous cell
carcinoma---involving the glottis (n=6), surpraglottis (n=5), oropharynx
(n=2), nasopharynx (n=2), hypopharynx (n=1), and oral cavity (n=1). Mean
follow-up after surgery was 19.1 months with 6 month follow up.

Operative notes dictated by the primary operative surgeon (JMS) of all
reconstructions were reviewed. All patients underwent microvascular
reconstruction with a fasciocutaneous SFTT in a circumferential/tubed
(n=11) or partially-tubed (n=6) fashion. All patients were positioned in
lateral decubitus for harvest (Figure 1), and donor sites closed
primarily (Figure 2). Flap pedicles were based off the subscapular or
circumflex scapular artery and veins. Recipient arteries included facial
(n=5), superior thyroid (n=4) and transverse cervical (n=6) arteries.
The external jugular vein (n=7) or branches off the internal jugular
vein (n=9) were used. An implantable doppler was coupled to the
recipient vein for postoperative monitoring. Mean skin paddle size was
152.2cm\textsuperscript{2} (SD 56.2cm\textsuperscript{2}, range
67.5-242cm\textsuperscript{2}) and average ischemia time was 4 hours
(range 2:57-4:50). Majority of hypopharyngeal reconstruction was
completed prior to starting microvascular anastomosis. Salivary bypass
tubes were placed at the time of surgery in 14 patients.

All patients were admitted to the surgical-trauma ICU for hourly flap
checks. Flap survival rate was 100\%. Donor site morbidity comprised two
post-operative hematomas requiring drainage and wound vac placement.
There was no wound infections or dehiscence. Post-surgical complications
included two hematomas (one neck, one chest) and two cases of wound
dehiscence (one at flap edge, one at stoma).

Two patients developed PCF as inpatients (11.7\%). One fistula was
closed with pectoralis flap successfully, and other with packing and use
of a wound vacuum device. There was one major complication (pulmonary
embolism) and 7 minor complications (Table 2). Mean hospital length of
stay was 15.7 days (SD 8.2, range 8-36 days). Ten out of 17 patients
received post-adjuvant therapy (chemoradiation, chemotherapy- or
radiation-alone).

Speech outcomes in the outpatient setting were reviewed and are detailed
in table 3. Pre-operatively, nutritional status was generally poor with
only 7 patients able to fulfill nutritional needs via oral intake. In
the postoperative setting, one patient remained PEG-dependent, 11
supplemented with PEG feeds, and 5 were taking solely by mouth. Four
patients required esophageal dilation in the operating room. In many
cases, swallowing outcomes were affected by pre-operative swallowing
dysfunction including trismus and multi-level swallowing difficulty.
Swallowing outcomes often worsened after adjuvant treatment.

Voice outcomes varied significantly among patients in the cohort (Table
3). Four patients remained with only text/written speech for
communication, 6 patients pursued TEP placement and were progressing
with voice rehabilitation, 7 patients utilized an electrolarynx with
varying degrees of success.

\textbf{DISCUSSION}

Dos Santos first published on the anatomy of the subscapular system and
introduced the scapula free flap\textsuperscript{6}. Since its original
description, few series have focused on the fasciocutaneous iteration of
the SFTT. Yoo et. al. detailed their experience in 60 patients with only
29 requiring fasciocutaneous free flaps\textsuperscript{7}. Only one
patient required hypopharyngeal reconstruction. Another series of 130
patients had only four patients requiring fasciocutaneous
flaps\textsuperscript{8}.

The utilization of non-radiated, vascularized tissue for closure of
post-laryngectomy defects has become standard of care. The
scapular/parascapular free flap is a safe and reliable option for
hypopharyngeal reconstruction. Eighty-eight percent of our patients had
failed non-surgical treatment.

All scapula free tissue transfers remained viable for the duration of
this review. This flap survival rate is comparable to the large
retrospective series of radial forearm and anterolateral thigh (ALT)
free flap reconstruction post-laryngectomy\textsuperscript{9,10}. PCF
developed in two patients in post-operative setting. Published PCF rates
after laryngectomy vary widely. Yu et. al. reported a 8.8\% PCF rate for
PE defect reconstruction\textsuperscript{11}. The majority of patients
underwent free tissue reconstruction (92\%) with higher rates of fistula
in circumferential vs. partial defects (11\% vs. 6\%). These figures are
comparable to our PCF rate of 11.7\%.

Few patients had major or minor events during the inpatient hospital
stay. One patient developed venous thromboembolism despite prophylaxis,
which was treated without complication with therapeutic anticoagulation.
Seven patients had minor hospital complications which responded to
conventional treatments (table 2). This was comparable to other
published results of PE defect reconstruction or
SFTT\textsuperscript{11,12}.

SLP outcomes were followed closely pre- and post-operatively in our
cohort of patients. Oral intake was reestablished in 94.1\% of patients
with five not requiring G-tube for supplementation. Several patients
required supplemental nutrition due to multilevel swallowing
dysfunction, debilitation due to adjuvant treatment, and cancer
recurrence. Six patients were able to undergo TEP placement, and all had
excellent voice outcomes as determined by SLP evaluation. The remaining
patients are currently using electrolarynx or text/written
communication.

Donor site morbidity was limited as all back wounds were closed
primarily at the time of flap harvest with drain placement in surgical
bed and incisional negative pressure therapy as
needed.\textsuperscript{13} Two patients developed back hematomas and
were treated successfully at the bedside. Two other patients had minor
wound dehiscence along the harvest site which healed without need for
further intervention. All patients participated in inpatient physical
therapy after surgery with no limits on weight bearing or range of
motion. Other authors' experiences with SFTT donor site morbidity have
also been quite favorable\textsuperscript{12,14}.

The ALT flap has become gold standard for free tissue transfer for its
ability to harvest large fasciocutaneous flaps capable of having
multiple skin islands. Also, concurrent harvest of the ALT flap during
ablative surgery is more efficient compared to SFTT. On the other hand,
SFTT is capable of creating large skin paddles without concern for
closing under extreme tension. SFTT also has much more reliable anatomy
with vascular pedicle not affected by atherosclerotic changes. The SFTT
is a robust flap since blood supply to the skin paddle is not based on
perforator dissection. Pedicle length is usually increased in ALT flap,
but since the SFTT is versatile in terms of orientation, this advantage
is limited in the neck.

Though our outcomes using SFTT are encouraging our study has a small
sample size without a control group. Further studies will aim to
prospectively compare outcomes between SFTT and other free flaps in PE
defect reconstruction.

This study presents SFTT as a viable option for reconstruction of PE
defects. It provides adequate soft tissue coverage with a reliable,
large caliber vascular pedicle with minimal donor site morbidity.
Functional outcomes regarding speech and swallowing with SFTT for
post-laryngectomy defects are comparable to other reconstructive
options. Though this flap may not be the first option for
reconstruction, it should be a consideration in complicated
hypopharyngeal defects.

\textbf{REFERENCES}

1.Dowthwaite SA, Theurer J, Belzile M, et al. Comparison of fibular and
scapular osseous free flaps for oromandibular reconstruction: a
patient-centered approach to flap selection. JAMA Otolaryngol Head Neck
Surg. 2013;139(3):285-92.

2.Valentini V, Gennaro P, Torroni A, et al. Scapula free flap for
complex maxillofacial reconstruction. J Craniofac Surg.
2009;20(4):1125-31.

3.Morrissey AT, O'connell DA, Garg S, Seikaly H, Harris JR. Radial
forearm versus anterolateral thigh free flaps for laryngopharyngectomy
defects: prospective, randomized trial. J Otolaryngol Head Neck Surg.
2010;39(4):448-53.

4.Welkoborsky HJ, Deichm\selectlanguage{ngerman}üller C, Bauer L, Hinni ML. Reconstruction of
large pharyngeal defects with microvascular free flaps and myocutaneous
pedicled flaps. Curr Opin Otolaryngol Head Neck Surg. 2013;21(4):318-27.

5.Hanasono MM, Lin D, Wax MK, Rosenthal EL. Closure of laryngectomy
defects in the age of chemoradiation therapy. Head Neck.
2012;34(4):580-8.

6.Dos santos LF. The vascular anatomy and dissection of the free
scapular flap. Plast Reconstr Surg. 1984;73(4):599-604.

7.Moukarbel RV, White JB, Fung K, Franklin JH, Yoo JH. The scapular free
flap: when versatility is needed in head and neck reconstruction. J
Otolaryngol Head Neck Surg. 2010;39(5):572-8.

8.Mitsimponas KT, Iliopoulos C, Stockmann P, et al. The free
scapular/parascapular flap as a reliable method of reconstruction in the
head and neck region: a retrospective analysis of 130 reconstructions
performed over a period of 5 years in a single department. J
Craniomaxillofac Surg. 2014;42(5):536-43.

9.Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal
reconstruction with the anterolateral thigh flap after total
laryngopharyngectomy. Cancer. 2010;116(7):1718-24.

10.Scharpf J, Esclamado RM. Reconstruction with radial forearm flaps
after ablative surgery for hypopharyngeal cancer. Head Neck.
2003;25(4):261-6.

11.Selber JC, Xue A, Liu J, et al. Pharyngoesophageal reconstruction
outcomes following 349 cases. J Reconstr Microsurg. 2014;30(9):641-54.

12.Gibber MJ, Clain JB, Jacobson AS, et al. Subscapular system of flaps:
An 8-year experience with 105 patients. Head Neck. 2015;37(8):1200

13.Schmedes GW, Banks CA, Malin BT, Srinivas PB, Skoner JM. Massive flap
donor sites and the role of negative pressure wound therapy. Otolaryngol
Head Neck Surg. 2012;147(6):1049-53.

14.Ferrari S, Ferri A, Bianchi B, Varazzani A, Perlangeli G, Sesenna E.
Donor site morbidity after scapular tip free flaps in head-and-neck
reconstruction. Microsurgery. 2015;35(6):447-50

\textbf{FIGURE LEGENDS}

Figure 1: Scapular flap harvest - Positioning and Post-Dissection
Anatomy

Teres Major Muscle B. Triceps Muscle C. Teres Minor Muscle

Figure 2: Donor Site Primary Closure

Left: Intra--operative photo Right: First post-operative visit photo\selectlanguage{english}
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\textbf{Hosted file}

\verb`Tables.docx`  available at \url{https://authorea.com/users/329769/articles/473965-scapular-free-flap-reconstruction-of-pharyngoesophageal-defects}

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