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Ann Thorac Surg 2006;81:714-716
© 2006 The Society of Thoracic Surgeons

Case report

Human Tracheal Reconstruction With a Composite Radial Forearm Free Flap and Prosthesis

Peirong Yu, MD a , * , Gary L. Clayman, DMD, MD b , Garrett L. Walsh, MD c

a Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
b Department of Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
c Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas

Accepted for publication December 16, 2004.

* Address correspondence to Dr Yu, Department of Plastic Surgery, Unit 443, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 (Email: eirongyu{at}mdanderson.org).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Reconstruction of large tracheal defects has been largely unsuccessful. We report a novel single-stage tracheal reconstruction for a 6.5-cm long defect involving the anterior two thirds of the tracheal circumference in a patient with deeply infiltrative thyroid cancer into the tracheal lumen. The reconstruction was completed using a conduit composed of a radial forearm free flap for lining with a combined PolyMax mesh (Synthes, Paoli, PA) and Hemashield vascular graft (Boston Scientific, Natick, MA) for rigid support. At a 6-month follow-up the patient has normal swallowing and preoperative voice quality, and she maintains a patent, non-stented airway.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Tracheal reconstruction after surgical resection is difficult because of the trachea's intrinsic rigidity, intact luminal lining, and ability to clear secretions. A short tracheal defect of as much as 2 cm may be closed primarily or patched [1]. Extended resection up to 4 cm may be reapproximated with the neck at 15 to 35 degrees of flexion and laryngeal release to minimize anastomotic tension [2]. A defect between 4 and 6 cm may still be closed with additional airway mobilization and hilar release in a few specialized centers. However, anastomotic complications and mortality rates increase with increasing length of the defect [2]. A defect longer than 6 cm has not been successfully reconstructed in humans. In this report we describe a new technique of tracheal reconstruction for a 6.5 cm defect that would have mandated a permanent tracheostomy.

A 63-year-old, otherwise healthy woman was referred to our center for a recurrent papillary thyroid carcinoma after a total thyroidectomy and iodine treatment 14 years earlier. She had persistent mild dysphagia and left vocal cord paralysis since her initial surgery. Physical examination now demonstrated a 4-cm mass in the left lower neck that was fixed to the underlying trachea. Computed tomography confirmed a large mass in the central cervical compartment with destruction of the tracheal rings, infiltration into the cervical esophagus, and effacement of the internal jugular vein (Fig 1). Bilateral neck dissection, comprehensive resection of the cervical trachea and esophageal musculature were performed. The resulting defect included the inferior quarter of the thyroid cartilage and the anterior two thirds of the cricoid cartilage and cervical trachea (Fig 2, top left). The total length of the defect was 6.5 cm.


Figure 1
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  		Fig 1. Computed tomographic scan showing a recurrent thyroid cancer invading the trachea.

 

Figure 2
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  		Fig 2. Intraoperative photographs showing a 6.5-cm long tracheal defect (top left), fabrication of the neotrachea (top right), insetting of the neotrachea (bottom left), and partial coverage of the neotrachea with the sternocleidomastoid muscle (bottom right).

 
To preserve her laryngeal function as well as avoid a permanent tracheostomy, an immediate tracheal reconstruction was performed. A left radial forearm fasciocutaneous flap was chosen to line the neotrachea. Rigid support was provided with a 26-mm diameter Hemashield vascular graft (Boston Scientific, Natick, MA) and reinforced with a 0.5-mm thick PolyMax resorbable mesh (Synthes, Paoli, PA) (Fig 2, top right). The mesh was contoured to a circular shape with a diameter of 3 cm. The Hemashield graft (Boston Scientific) was placed outside the mesh. The radial forearm flap was suspended to the mesh and the graft with multiple 3-0 Proproplene sutures (Ethicon Inc, Somerville, NJ) through the dermis of the flap but not through the skin surface. This composite neotrachea with a length of 6 cm was then transferred using microsurgical techniques to reconstruct the tracheal defect (Fig 2, bottom left and right). The flap vessels were anastomosed to the left transverse cervical artery and vein using 9-0 nylon sutures. A Montgomery T-tube (Boston Medical Products Inc, Westborough, MA) was placed through a temporary tracheostomy to prevent potential airway compromise secondary to postoperative edema. The patient was awakened; she was breathing spontaneously and was monitored in the intensive care unit for 3 days, during which time daily bronchoscopy was performed through the T-tube to assess the flap. The flap remained well perfused with moderate edema for 2 days. Resolution of the edema was seen on postoperative day 3 when she was started on a regular diet. She was discharged on postoperative day 8.

The patient has returned to normal activities without any respiratory compromise since discharge. The T-tube was removed 2 months postoperatively prior to initiation of external beam radiotherapy. She received a total of 60 Gy in 30 fractions over 6 weeks. She remains symptom free at her 6-month follow-up with complete healing of the T-tube track. Bronchoscopy at 6 months revealed a well healed flap with mild paradoxic movement into the lumen on inspiration (Fig 3). The entire airway appeared clean, with no evidence of keratin debris or sebaceous secretions, or mucus accumulation. She lives a normal life, continues to tolerate a regular diet, and maintains a preoperative voice quality.


Figure 3
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  		Fig 3. Bronchoscopy at 6 months showing a completely healed flap with a patent airway.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Tracheal reconstruction for large defects has been a surgical challenge due to the need for rigid support and epithelial lining, as well as effective clearance of airway secretions. Reconstruction with a soft tissue flap alone will inevitably collapse. Intraluminal stenting with a prosthesis causes constant irritation and inflammatory responses resulting in problematic secretions. This was demonstrated by Beldholm and colleagues [3] who reported the reconstruction of a 6-cm long tracheal defect using a radial forearm flap and internal stenting. The patient had repeated episodes of pneumonia develop due to constant secretions and ultimately stricture formation.

Our patient had a partial tracheal destruction from a recurrent thyroid cancer and a 6.5-cm long defect after surgical ablation. A novel single-stage reconstruction provided the patient excellent quality of life with normal deglutition and speech. To restore the tracheal continuity to its most physiologic condition, the soft tissue lining needs to be supported by rigid materials that are placed around it, not inside the lumen. Ideally, the supporting material has already been well integrated with the soft tissue lining at the time of reconstruction to avoid separation of the lining and airway collapse. This necessitates a two-stage reconstruction. Matloub and Yu [4] have successfully engineered such a neotrachea in a rat model using a Ring GoreTex vascular graft (W. L. Gore & Associates, Flagstaff, AZ) for support with a soft tissue flap for lining. The GoreTex graft was found to be completely integrated with the soft tissue in 3 weeks. Such a two-stage reconstruction is currently being tested in large animals. Our experience with this case has demonstrated that separation of the soft tissue lining from the supporting material can be prevented by suspending the lining flap to the prosthesis using permanent sutures.

The Ring Gortex graft has adequate rigidity and some flexibility and longitudinal elasticity, mimicking the native trachea. In this case, however, a large enough Ring GoreTex graft was unavailable. Therefore, the largest available Hemashield graft (Boston Scientific) was chosen, which did not provide adequate rigid support. To reinforce rigidity, the PolyMax resorbable mesh (Synthes) was incorporated into the conduit. This mesh, which is contourable in hot water (70°C) and lasts 18 to 24 months before resorption, has been widely used for craniofacial reconstruction. It was hoped that the remaining Hemashield graft (Boston Scientific) and scarring would maintain the rigidity once the PolyMax mesh (Synthes) resorbs.

With this novel technique the reconstruction was accomplished in 4 hours, and no laryngeal or hilar release or neck flexion was required. The patient returned to normal activity quickly. With advances in microsurgery and high free flap success rates, microsurgical reconstruction of the trachea may play an important role in the future.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Belsey R. Resection and reconstruction of the intrathoracic trachea Br J Surg 1950;38:200.[Medline]
  2. Mitchell JD, Mathisen DJ, Wright CD, et al. Resection for bronchogenic carcinoma involving the carinalong-term results and effect of nodal status on outcome. J Thorac Cardiovasc Surg 2001;121:465.[Abstract/Free Full Text]
  3. Beldholm BR, Wilson MK, Gallagher RM, et al. Reconstruction of the trachea with a tubed radial forearm free flap J Thorac Cardiovasc Surg 2003;126:545-550.[Abstract/Free Full Text]
  4. Matloub HS, Yu P. Engineering a composite neotrachea in a rat model Plast Reconstr Surg 2004; (in press)..



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This Article
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