Tracheal Reconstruction with Radial Forearm Free Flap and Cartilage Graft: A Case Report

Caitlin Bertelsen, Karla O’Dell and Niels Kokot

Department of Otolaryngology and Head and Neck Surgery, Keck School of Medicine of the University of Southern California, USA

^*Correspondance to: Niels Kokot 

 PDF  Full Text DOI: 10.25107/2474-1647.1332

Abstract

Introduction: Circumferential tracheal defects of less than 4-6 cm may be safely resected with primary anastomosis. Larger or irregular defects often require reconstructive surgery, which is often challenging. A successful tracheal reconstruction maximally preserves respiratory epithelium and local blood flow, and includes a rigid component to prevent inspiratory airway collapse. No consensus exists regarding an optimal solution to this problem. We present a case of tracheal reconstruction with a radial forearm free flap and costal cartilage graft as a method of restoring tracheal continuity and function.Materials and
Methods: The patient’s tracheal adenoid cystic carcinoma was resected, leaving an irregular tracheal defect of about 5.5 cm in length. A costal cartilage graft of 7 cm was sutured to a 6 x 6 cm radial forearm fasciocutaneous flap. Microvascular anastomosis was performed and the cartilage-bolstered flap was sewn into the tracheal defect. Tracheostomy and nasogastric tubes were placed intraoperatively.Results: The patient was able to swallow by postoperative day 7, allowing removal of the nasogastric tube. His tracheostomy tube was removed on postoperative day 14. Three years after surgery, the patient maintains a patent airway with good speech and swallowing functions and no respiratory complaints. He has had no major complications.Conclusion: Radial forearm free flap with costal cartilage graft represents a safe way to repair large tracheal defects with preservation of speech and swallowing. Advantages of the procedure described include applicability to a wide variety of defects as well as ability to be carried out in a single stage. Caitlin Bertelsen, Karla O’Dell and Niels Kokot* Department of Otolaryngology and Head and Neck Surgery, Keck School of Medicine of the University of Southern California, USA Introduction Management of tracheal defects differs based on size, shape and location. Defects less than 4-6 cm or 6 tracheal rings may be safely resected with primary anastomosis [1]. This is often technically difficult when laryngeal and hilar release procedures are required, which may interrupt tracheal innervation and blood supply and cause dysphagia. For large or irregular tracheal defects, airway reconstruction is frequently necessary and presents several challenges. A successful tracheal reconstruction preserves respiratory epithelium, maintains blood flow, and structurally resembles the native trachea. While a rigid component is desirable to prevent inspiratory airway collapse, intraluminal stent use for this purpose often leads to fibrosis or stent migration [2]. Disruption of tracheal blood supply during resection has also hindered reconstruction [3]. Recently, there has been increasing utilization of microvascular free tissue transfer to solve this problem. Free flaps are used frequently in reconstruction of the head, neck, and chest with good functional outcomes. Use of the radial forearm free flap (RFFF) for tracheal defects has been reported in several small series [4-8]. Adjuncts, including biodegradative mesh [9] or other non-resorbable material [6-8] as well as costal or auricular cartilage [5,10-12] or long bone [13,14] have been used to provide rigid support to a free soft tissue flap. While successful reconstructive outcomes have been reported, several patients in these series have experienced significant complications. There is currently no consensus regarding an optimal reconstructive procedure or combination of materials. We propose that tracheal reconstruction with a radial forearm free flap and costal cartilage graft represents a reliable method of airway reconstruction with preservation of speech and swallowing functions without need for long-term tracheotomy.

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Cite the article

Bertelsen C, O'Dell K, Kokot N. Tracheal Reconstruction with Radial Forearm Free Flap and Cartilage Graft: A Case Report. Clin Surg. 2017; 2: 1332.