Full text of DOI:10.1097/00005537-200203000-00031

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2002 The American Laryngological,
Rhinological and Otological Society, Inc.
How I Do It
A Targeted Problem and Its Solution
Monitoring of Partial Pharyngeal
Reconstruction
Juan M. Alcalde, MD; Juan L. Quesada, MD
INTRODUCTION
the flap, we de-epithelialize approximately 2 cm of the
The goal in pharyngeal surgery is to achieve surgical
margins free of tumor. In some cases it is necessary to
perform a wide pharyngectomy that is difficult to close
without a reconstructive procedure. In our centers we use
the radial forearm free flap when pharyngeal reconstruc-
tion is necessary. This is a pliable, thin flap with a large
pedicle that makes the reconstruction and the microvas-
cular anastomosis easy to perform.1 In reconstruction of
pharyngeal defects with free flaps, the location of the flap
is inconvenient for visual monitoring. Usual monitoring
techniques are direct visualization, Doppler ultrasound,
laser Doppler, and fluorescein injections.2 Clinical assess-
ment of the flap is the method of choice, although this is
not always possible.
distal part of the flap, leaving 2 cm distally with the
forearm skin intact (Fig. 1). The distal 2-cm portion is
used for clinical assessment of the viability of the flap
under direct view. When the flap is harvested, we suture
the flap to the residual pharyngeal mucosa, leaving the
2-cm portion distal to the flap not sutured. When we finish
suturing the pharyngeal mucosa, we perform the micro-
vascular anastomosis. After the microvascular anastomo-
sis we begin to close the cervical skin. When we arrive at
the monitor segment of the forearm flap, we suture it to
the posterior wall of the trachea and to the cervical skin
(Fig. 2). The skin monitor segment is useful in monitoring
the flap because it has the same vascular pedicle as the
rest of the flap that is used for pharyngeal reconstruction.
For individuals who are familiar with patients having
reconstructive procedures, this skin paddle is easy to
monitor.
For the monitoring of total pharyngectomy, we have
been using the design of Urken et al.3 with a small seg-
ment to be monitored connected to the primary skin pad-
dle by a fascial subcutaneous segment of tissue. This mon-
itor segment is exteriorized in the neck to provide clinical
monitoring of the flap. Because of the inconvenience of
this segment, we tried to find a simpler method for mon-
itoring cases in which we employed the radial forearm flap
for pharyngeal reconstruction.
PATIENTS AND METHODS
The present report includes four patients who underwent a
partial pharyngeal reconstruction with the radial forearm free
flap during 1999 at the University Clinic of Navarra (Pamplona,
Spain) and Valle Hebro´n Hospital (Barcelona, Spain). All primary
lesions were squamous cell carcinomas of the pharyngeal wall
that involved the larynx. One patient had been treated previously
with chemotherapy, radiotherapy, and a total laryngectomy and
had a pharyngeal stenosis. In the patients with no prior treat-
ment a partial pharyngectomy with total laryngectomy was per-
formed, and in the patient treated previously, because of pharyn-
geal stenosis, only a partial pharyngectomy was performed. Two
patients had an unilateral cervical neck dissection (one radical
and one functional neck dissection), and one patient had a bilat-
eral neck dissection at the time of the surgery. The patient
treated previously with a total laryngectomy had the neck dissec-
tion performed previously. The three patients with no prior treat-
ment were given full-course radiotherapy 1 month after discharge
from the hospital.
TECHNIQUE
The essential steps in harvesting the radial forearm
flap are well described in many reports, so we describe
only the changes we have made in our design.
We designed our flap to be 4 cm longer than the
extension we need for the pharyngeal defect, usually 12
cm in length and 6 cm in width. After we have harvested
From the Department of Otolaryngology—Head and Neck Surgery
(J.M.A.), University Clinic of Navarra, Pamplona, Spain, and the Depart-
ment of Otolaryngology—Head and Neck Surgery (J.L.Q.), Vall d’Hebro´n
University Hospital, Barcelona, Spain.
Editor’s Note: This Manuscript was accepted for publication July 17,
2001.
Send Correspondence to Juan L. Quesada, MD, P San Gervasio 59 3,
08022 Barcelona, Spain. E-mail: jquesada@hg.vhebron.es
RESULTS
All four radial forearm flaps were successfully trans-
ferred. No patient required any additional surgical proce-
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Alcalde and Quesada: Pharyngeal Reconstruction

Fig. 1. Free radial forearm flap har-
vested. It is possible to view two islands,
one for pharyngeal reconstruction and
the other for monitoring.
dure. All the patients began oral soft food intake by the
14th day with no salivary fistula. The four patients were
discharged from the hospital between the 13th and 15th
day after the surgery.
advantages over other reconstructive methods.1 Although
the radial forearm free flap is highly reliable in all cases,
with its use in pharyngeal reconstruction, clinical moni-
toring is inconvenient because of the location of the flap.
Although the design of Urken et al.3 is useful, it has the
disadvantage that sometimes a much longer pedicle must
be obtained than is needed. Also, it is necessary to adapt
the monitor island to the cervical skin by making a hole in
the skin surface and suturing the island.
With our design, the adaptation of the skin monitor
segment is much easier because we suture it to the supe-
rior part of the tracheostomy and the inferior border of the
superior cervical flap. It has the advantage that the blood
supply to the monitor island is the same as to the rest of
the flap, with no need to obtain excessive fascial-
subcutaneous tissue to maintain vascularization to the
island.
The skin segment to be monitored was a reliable and
easy clinical monitor of the circulation to the flap in all
cases. The nurses at the intensive care unit monitored the
flap every 4 hours within the first 48 hours; then, at the
patient’s room, both the ENT physician and the nurse
performed the monitoring every 12 hours for 3 more days.
The aesthetic result was good, and the skin monitor
segment was usually covered by the tracheal canula.
There were no major complications, and only minor
complications occurred at the donor site in two patients
with a partial tendon exposure that resolved within 1
month.
DISCUSSION
We have been using the radial forearm flap for hypo-
pharyngeal reconstruction since 1994 because it offers
The only complication that occurred in our patients
was a tendon exposure in two cases, and we do not think
that this was a result of the design itself. There were no
Fig. 2. Monitoring island between the
tracheostomy and the superior cervical
skin.
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Alcalde and Quesada: Pharyngeal Reconstruction
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2. Disa JJ, Hu QY, Hidalgo DA. Retrospective review of 400
consecutive free flap reconstruction for oncologic surgical
defects. Ann Surg Oncol 1997;4:663–669.
3. Urken ML, Furtran N, Moscoso JF, Biller HF. A modified
design of the buried radial forearm free flap for use in oral
cavity and pharyngeal reconstruction. Arch Otolaryngol
Head Neck Surg 1994;120:1233–1239.
additional complications because of the greater amount of
tissue that we harvested for monitoring, and our compli-
cation rate was quite good,4 although this may be attrib-
utable to the small number of cases in our series.
BIBLIOGRAPHY
4. Evans GR, Schusterman MA, Stephen SK, et al. The radial
forearm flap for head and neck reconstruction: a review.
Am J Surg 1994;118:446–450.
1. Kelly KE, Anthony JP, Singer M. Pharyngoesophageal reconstruc-
tion using the radial forearm fasciocutaneous free flap: prelim-
inary results. Otolaryngol Head Neck Surg 1994;111:16–24.
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