Welkoborsky Hans-J, Deichmüller Cordula, Bauer Lothar, Hinni Michael L
Department of Otorhinolaryngology, Head Neck Surgery, Nordstadt Clinic-Academic Hospital, Hannover, Germany.
Curr Opin Otolaryngol Head Neck Surg. 2013 Aug;21(4):318-27. doi: 10.1097/MOO.0b013e3283631ea2.
The current review will focus on the therapeutic options for reconstruction of large and complex defects of the oropharynx and hypopharynx, and the cervical esophagus following surgery for squamous cell carcinoma. The advantages and disadvantages of pedicled flaps, including the pectoralis major myocutaneous flap (PMMF) and supraclavicular artery flap (SAF), as well as the fasciocutaneous free flaps, including the radial forearm free flap (RFFF), the anterolateral thigh flap (ALT), and the jejunum free flap, are reviewed with particular emphasis on the literature from the past 2 years.
For partial pharyngeal defects, several reconstructive options, that is, PMMF, RFFF, SAF, and ALT might all be appropriate. When large mucosal surfaces need reconstruction, RFFF seems to be the most utilized. Nevertheless in reviewing the literature, no specific pedicled or free flap seems superior over other options. In cases of tongue reconstruction ALT or RFFF may be appropriate. After circumferential resections of the hypopharynx and cervical esophagus, free flaps achieve a significantly lower fistula and stricture rate compared to pedicled flaps with ALT and free jejunal flaps being used most commonly. However, donor-site morbidity and the complications of jejunal harvesting can be significant. Due to its great versatility, good reported functional and oncological outcomes, and reduced overall complication rate, the ALT flap warrants consideration. Finally, transoral robotic surgery (TORS) may provide future options for reconstruction.
Currently the head and neck surgeon has a diverse armamentarium available to reconstruct even large and complex pharyngeal defects. Selecting the best reconstructive option must be individualized. Fasciocutaneous free flaps, that is, RFFF and especially ALT, are assuming a greater progressive role in pharyngeal reconstruction. TORS may eventually lead to new options for reconstructive surgery.
本综述将聚焦于口咽和下咽以及颈段食管鳞状细胞癌手术后大型复杂缺损的重建治疗方案。回顾了带蒂皮瓣（包括胸大肌肌皮瓣（PMMF）和锁骨上动脉皮瓣（SAF））以及筋膜皮游离皮瓣（包括桡侧前臂游离皮瓣（RFFF）、股前外侧皮瓣（ALT）和空肠游离皮瓣）的优缺点，特别强调了过去两年的文献。
对于部分咽部缺损，几种重建方案，即PMMF、RFFF、SAF和ALT可能都适用。当需要重建大面积黏膜表面时，RFFF似乎是最常用的。然而，在回顾文献时，没有一种特定的带蒂或游离皮瓣似乎比其他方案更具优势。在舌重建的情况下，ALT或RFFF可能适用。在下咽和颈段食管环形切除术后，与带蒂皮瓣相比，游离皮瓣的瘘管和狭窄发生率显著降低，其中ALT和空肠游离皮瓣最常使用。然而，供区并发症和空肠获取的并发症可能很严重。由于其多功能性、良好的功能和肿瘤学结果报告以及总体并发症率降低，ALT皮瓣值得考虑。最后，经口机器人手术（TORS）可能为重建提供未来的选择。
目前，头颈外科医生有多种可用的手段来重建甚至是大型复杂的咽部缺损。选择最佳的重建方案必须个体化。筋膜皮游离皮瓣，即RFFF，尤其是ALT，在咽部重建中发挥着越来越重要的作用。TORS最终可能会带来重建手术的新选择。
