Hypopharynx

Reconstruction of the hypopharynx introduces another variable that influences the selection of the optimal reconstructive technique because of the proximity to the larynx. Once again, the musculocutaneous or free flaps are frequently used for these reconstructions. Partial hypopharyngeal reconstructions can be effectively achieved in a one-stage fashion with either musculo-cutaneous flaps or free flaps that have the ability to restore func-tion.23-26 We usually prefer musculocutaneous flaps because of the high success rate and shorter operative time as compared with the free flaps.

compromise of the functional results as a result of a high incidence of stenoses at the distal anastomosis of the remaining esophagus to the flap. The use of musculocutaneous flaps offers the potential to complete this reconstruction in one stage. However, past experience demonstrates that the frequency of a successful reconstruction is still unsatisfactory using the mus-culocutaneous flaps.23,24 Free flaps provide the opportunity for transferring a thin piece of vascularized tissue that reestablishes the continuity of the conduit and seemingly has a lower incidence of stenosis at the distal junction. This enables restoration of swallowing function and the potential for vocal rehabilitation with creation of a tracheoesophageal fistula and insertion of a voice prosthesis.

However, which free flap provides superior results remains somewhat controversial. Jejunal segment free flaps have been described in the literature as an effective reconstructive approach.30,31 Apparent disadvantages to jejunal free flaps are their association with increased morbidity because other body cavities (i.e, the abdomen) are entered, and they require yet another surgical team to harvest the flap. Jejunal segments also do not undergo neovascularization from the surrounding tissues, and, accordingly, subsequent operations that are performed in the area of the vascular pedicle for recurrent cancer or other problems can put the total viability of the jejunal segment in jeopardy. In addition, it is unusual to achieve voicing with tra-cheoesophageal speech in those patients who have undergone reconstruction of the pharyngoesophagus with jejunal segment. As a result, radial forearm free flaps have emerged as a popular approach to this reconstructive task and provide a highly vascular reliable flap that appears to have a high rate of successful restoration of swallowing and speaking function.25,32,33

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