Externalized Monitoring of Totally Buried Free Flap in Hypopharyngeal Reconstruction

Purpose: Defects after ablation for the treatment of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Because the neohypopharynx is totally buried, various methods have been suggested for monitoring. Here, we propose techniques that can be used to monitor the buried fasciocutaneous free flap for reconstruction after pharyngolaryngectomy, which has an exteriorized part that can be used for clinical monitoring. Materials and Methods: Between January 2011 and May 2012, 6 consecutive patients with advanced hypopharyngeal cancer underwent reconstructive surgery of the fasciocutaneous free flap after pharyngolaryngectomy. The anterolateral thigh free flap was used in 4 patients, and the radial forearm free flap was used in the other 2 patients. All flap designs were elongated into a fusiform shape because a part of the flap was used for exteriorized monitoring using deepithelialized bridge. Results: Patients 1 and 2 demonstrated uneventful postoperative courses, including healthy skin color and fresh pin-prick bleeding. Patient 3 also demonstrated a healthy monitoring flap, but distal leakage was noted on the computed tomographic scan, and Fistula repair with monitoring flap excision was performed on postoperative day 16. In patient 4, defects that manifested after cancer ablation were shorter than usual, and deepithelialized bridge was longer. When the general hemodynamic status of the patient was aggravated during the postoperative course, the color of the monitored skin did change. The viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks, and repair was necessary. Patients 5 and 6 demonstrated healthy monitoring flap and no postoperative complications. The monitoring flap was excised after 2 weeks under local anesthesia. Conclusions: Using our techniques, clinical monitoring by examining the exteriorized monitoring flap is possible. However, the possibility of false positives exists, and physicians must be cautious when performing these techniques, and patients must be carefully selected because of the danger of leakage.