A full-thickness chondrocutaneous flap from the auricular concha for repair of tracheal defects

Immediate tracheal reconstruction with forearm flap and bone graft

BACKGROUND

"Window" resection of the trachea is sometimes performed to remove tumors invading the trachea. Here, we present a novel reconstructive procedure to this end.

METHODS

Eleven patients (mean age, 64 years; range, 46-80 years) were included. Primary diagnoses included thyroid cancer and adenoid cystic carcinoma of the trachea. All defects were partial and located in the neck (mean width and length, 3/5 circle and 7.5 rings; range, 1/2-2/3 circle and 5-9 rings). Immediate 2-stage reconstruction was performed using a forearm flap and free bone graft. The bone graft was utilized as a supportive skeleton. A tracheostoma was left open for several months following the initial surgery, and then closed.

RESULTS

The mean flap size was 6.1 × 9.7 cm (range, 6-7 × 7-16 cm). Mean number of grafted bone strips and length were 1.6 (range, 1-3) and 6.1 cm (range, 4.5-7 cm). All flaps survived. Five patients developed complications in the neck, including surgical site infections (SSIs), recurrent nerve palsy, and lymphorrhea. Four patients developed donor site complications, including clavicular fracture and SSIs. Mean postoperative follow-up lasted 85 months (range, 11-149 months). Normal speech was restored in 9 patients. Stoma closure was abandoned in 2 patients, because 1 patient showed vocal cord fixation with advanced age and the other showed bone graft loss following SSI.

CONCLUSIONS

Creating a tracheostoma during the first operation prevents postoperative airway compromise. Our bone graft placement easily achieves tracheal rigidity. This procedure is simple and safe for tracheal window defect repair.

Perforator flaps and supermicrosurgery

The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.

Microsurgical laryngotracheal reconstruction

Laryngotracheal reconstruction using free-tissue transfer represents one of the new challenges for the head and neck reconstructive surgeon. This article reviews the anatomy and physiology of the larynx and trachea and discusses the clinical context of laryngotracheal reconstruction, particularly with regard to malignant tumors involving the larynx and cervical trachea. It reviews the free-tissue reconstructive options, including the free forearm flap, the temporoparietal flap, and the two-staged procedure described by Delaere.

Reconstruction of an inner layer defect of the upper eyelid with avulsion of the superior levator palpebrae muscle and orbital fat

The authors report a successful reconstruction of the total upper eyelid in conjunction with the gliding surface of the extraocular muscles. A 21-year-old woman sustained an inner layer defect of her right upper eyelid together with avulsions of the superior levator palpebrae muscle and the superior orbital fat. Her right superior rectus muscle was exposed, and no orbital fat was seen in the space between the muscle and the orbital roof. To preserve eye movement, a gliding surface between the superior rectus muscle and the orbital roof had to be reconstructed. Total upper lid reconstruction was performed using a radial forearm flap with a hard palate mucosal graft. The gliding surface was reconstructed with an adipofascial flap obtained from the forearm. Despite lack of levator function, the patient could raise her eyelid approximately 5 mm by using only the superior rectus muscle without frontalis suspension.

Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear

Reconstruction of partial, marginal defects of the ear has been a challenge. The ascending helix free flap based on superficial temporal vessels has been described and used solely to repair nose defects. We used reversed pedicle helical free flap for the repair of a major loss of the upper one-third of the opposite auricle. The method permits the transfer of tissue of the same quality with satisfactory cosmetic result. The equalization of the ears in dimension was accomplished with minimal donor-site deformity.