Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 790e794

Tracheal reconstruction with a prefabricatedand double-folded radial forearm free flap

Takashi Fujiwara*, Kenichi Nishino, Toshiaki Numajiri

Department of Plastic and Reconstructive Surgery, Kyoto Prefectural University of Medicine,465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan

Received 29 May 2007; accepted 5 September 2007

KEYWORDSTrachealreconstruction;Tracheal defect;Prefabricated flap;Costal cartilage;Radial forearm freeflap;Microsurgery

* Corresponding author. Tel.: þ81 75732.

E-mail address: f-taka@koto.kpu-m

1748-6815/$-seefrontmatterª2008Bridoi:10.1016/j.bjps.2007.09.055

Summary We have described a prefabricated radial forearm free flap containing costalcartilage for tracheal reconstruction. The main advantages of this flap are that it requires onlyone piece of costal cartilage, simple cartilage trimming, and allows the possible reconstructionof both the internal lining and the external resurfacing when the flap itself is folded. This pro-cedure is easy and its outcome is stable. This flap is an attractive option for the reconstructionof large tracheal and skin defects, even in areas previously exposed to surgery or irradiation.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Publishedby Elsevier Ltd. All rights reserved.

Surgical treatment of malignancy or iatrogenic complica-tions of the neck often involve tracheal resection, leavinglarge tracheal defects. Untreated tracheal defects areunacceptable for patients because they entail aestheticdissatisfaction and a lower quality of life. The patient canneither produce a sound nor take a bath, and troublesomechanging of a cannula is required. Tracheal reconstruction ismandatory for patients who require extensive trachealresection. Although a large number of different procedureshave been used for tracheal replacement, no ideal re-construction has yet been established. The trachea isa unique and perfectly constructed organ, with rigid sup-port, an epithelial lining, and the ability to clear secretions.The ideal components of the reconstructive tissue would

5 251 5730; fax: þ81 75 251

.ac.jp (T. Fujiwara).

tishAssociationofPlastic,Reconstruc

include a lining, rigid support, and external resurfacing.Surgical repair of the trachea presents a number of chal-lenges because of its structural complexity. Several studieshave been undertaken with foreign materials, transplanta-tion, and tissue engineering. However, the main toolcurrently used in tracheal reconstruction is autogenoustissue, with which satisfactory and stable results havebeen achieved. For autogenous reconstruction, costal orauricular cartilage is widely used as a structural support andis buried in pedicle or free flaps. These prefabricationtechniques have a number of problems. They containa complex cartilage framework with which to restore thetracheal configuration and require multiple flaps to simul-taneously resurface the skin defect. When a regional pedicleflap is used for prefabrication, there is a higher risk ofinfection resulting from local tissue damage caused byprevious surgery and chemoradiotherapy. In this report,we describe a new technique for tracheal reconstruction

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Tracheal reconstruction 791

that provides a better blood supply and is easy to perform.This method consists of prefabrication with a piece of costalcartilage and the microsurgical transfer of composite tissue.We present a novel procedure for tracheal reconstructionusing an easy technique with a stable outcome.

Surgical technique

This procedure involves a two-staged reconstruction.

First surgical step

A piece of costal cartilage is harvested, trimmed almost ina straight line, and cut at both ends so that the length ofthe cartilage is approximately 2 cm longer than thetracheal and overlying skin defects. The cartilage is thenimplanted in the subcutaneous layer of the radial forearmharvest site (Figure 1a).

Second surgical step

Two months later, the prefabricated radial forearm flapcontaining the costal cartilage is raised by standardtechniques and transferred to the defect using microsurgi-cal techniques. A narrow strip, 5 mm in width, in the cen-tral part of the flap is de-epithelialised at the margins toallow suturing (Figure 1b). The flap is then folded and setinto the defect, with the ulnar side of the forearm skin,containing the costal cartilage, forming the tracheal liningand the radial side forming the external resurfacing(Figure 1c). Both ends of the costal cartilage are insertedinto subcutaneous pockets constructed over the residualtracheal edge, playing the role of a neotracheal strut.

Case reports

Case 1

A 54-year-old woman underwent a total thyroidectomy,combining a resection of the cervical trachea and a left

Figure 1 (aec) Schematic depiction of a prefabric

neck dissection for a papillary thyroid carcinoma. Theresulting anterior tracheal defect was approximately3.5 cm in length and involved 60% of the tracheal circum-ference (Figure 2a, b). She was referred to our departmentfor tracheal reconstruction. We decided to use a prefabri-cated composite radial forearm free flap. A sixth costal car-tilage was harvested, trimmed slightly, and then buried intothe subcutaneous layer of the left forearm (Figure 2c). Twomonths later, the prefabricated radial forearm flap washarvested (Figure 2d) and transferred to the neck. Theflap vessels were anastomosed to the right transversecervical artery and the internal and external jugular veinusing 9/0 nylon sutures. The flap was folded and appliedto the defect. A small tracheostomy tube was placed onthe left side of the flap to prevent potential airway compro-mise (Figure 2e), and a soft tracheal stent was kept in placefor 2 weeks. Three months later, the small tracheostomawas closed with local skin flaps. The wound healed well(Figure 2f, g). The patient returned to normal life withoutany respiratory or phonatory compromise.

Case 2

A 62-year-old woman underwent a total thyroidectomycombining a resection of the cervical trachea and a bilateralneck dissection for a papillary thyroid carcinoma. Thepatient was referred to us with a resulting tracheal defectof approximately 4.6 cm in length and involving 50% of thetracheal circumference (Figure 3a, b). Reconstructive sur-gery with a cartilage-containing radial forearm free flapwas performed. A seventh costal cartilage was harvestedand implanted in the left forearm. Two months later, the pre-fabricated radial forearm flap was elevated and transferredto the neck using microsurgical techniques. The left facialartery and the external and internal jugular vein were usedas recipient vessels. The flap was folded and sutured to thedefect without leaving a tracheostoma. The patient wasmonitored in the intensive care unit with orotracheal intuba-tion. The flap remained well perfused with moderateoedema. Extubation was performed on postoperativeday 5, when resolution of the oedema was observed.

ated and double-folded radial forearm free flap.

Figure 2 Case 1. (a, b) Preoperative appearance and computed tomographic scan of the neck, demonstrating the tracheal defect,which was approximately 3.5 cm in length and involved 60% of the tracheal circumference. (c) Prefabrication of the forearm.(d) Elevated prefabricated radial forearm flap. (e) Insetting the flap, leaving a small tracheostoma on the left sideof the flap. (f, g) Post-operative appearance and computed tomographic scan of the neck, demonstrating the widely patent and well-supported trachea.

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Figure 3 Case 2. (a, b) Preoperative appearance and computed tomographic scan of the neck, demonstrating the trachealdefect, which was approximately 4.6 cm in length and involved 50% of the tracheal circumference. (c, d) Postoperative appearanceand computed tomographic scan of the neck, demonstrating the well-healed wound and the excellent airway.

Tracheal reconstruction 793

Although the patient did not lapse into dyspnoea, her coursewas complicated by a small tracheocutaneous fistula and cu-taneous emphysema. After conservative treatment for 3weeks, the wound healed well, and the patient remainssymptom free (Figure 3c, d).

Discussion

A large number of different procedures have been used fortracheal replacement. Nevertheless, no ideal reconstructionhas yet been established. Tracheal reconstruction is a surgi-cal challenge because a lining, rigid support, and externalresurfacing are required. The many reconstructive methodscan be classified as follows: foreign materials, cadaverictissues, autogenous tissues, tissue engineering, and trachealtransplantation.1,2 Above all, significant advances have beenmade in tissue engineering. Omori et al. described a Marlexmesh tube covered by collagen sponge that was used fora tracheal reconstruction in a human patient.3 Althoughthe tracheal defect was small, a favorable result was ob-tained. Further development can be expected in this field.

At present, however, the main tool for tracheal recon-struction is autogenous tissue, which has minimal risk ofinfection or rejection and does not require immunosuppres-sion. Autogenous tissue is recognised as providing a betterblood supply and primary healing in unhealthy local tissue.When considering a tracheal reconstruction, it is essential

for surgeons to make an appropriate choice of methods andmaterials. Small tracheal defects can be closed primarily1 orby applying a composite graft, i.e. a nasal septal4 or trachealautologous5 graft. Conversely, large tracheal defects havebeen reconstructed with pedicle or free flaps, with rigid sup-port. Costal cartilage is well suited as a structural supportbecause of its peculiar properties: its rigidity prevents in-ward collapse, its flexibility allows it to move in concertwith the surrounding tissues, and it tends not to be ab-sorbed.6 Among the reconstructive procedures that use ped-icle flaps, Shinohara et al. reported a deltopectoral flapcombined with a costal cartilage graft and a palatal mucosalgraft.7 Nakahira et al. described a pectoralis major myocu-taneous flap combined with a costal cartilage graft.8 Thesemethods may be complicated in their construction or mayrequire multiple flaps. With advances in microsurgery andhigh free flap success rates, many microsurgical techniqueshave been advocated for tracheal reconstruction. The radialforearm flap has been widely used for free flap tracheal re-placement. The main advantages of this flap are its ease ofharvesting, the provision of a stable supply, and its pliabilityin prefabrication. Ten et al. created a prefabricated forearmfree flap using several curved costal cartilage strips.9 Oliaset al. used ring-shaped costal cartilage strips.10 These re-placements necessitated multiple costal cartilages andwere difficult to form. Beldholm et al. developed a tubed ra-dial forearm free flap and internal stenting, but experienced

794 T. Fujiwara et al.

problems with the formation of granulation tissue and exces-sive secretions.11 Yu et al. transferred a forearm free flap asa lining with a combined PolyMax mesh and Hemashield vas-cular graft for rigid support, which achieved favorable re-sults.12 This method may be an attractive option for single-stage tracheal reconstructions when there is no externalskin defect. In general, reconstructive procedures have re-quired complicated techniques, multiple flaps, and stagedoperations. Simpler and more reliable prefabrications wouldbe preferable.

In this report, we have presented a new technique oftracheal reconstruction using a prefabricated radial fore-arm free flap containing costal cartilage. This requiresa two-staged reconstruction, but it is both brief and stable.Only one piece of costal cartilage is required and trimmingit is very simple. A radial forearm free flap is easy toharvest, provides a better blood supply, and makes itpossible to reconstruct both the internal lining and theexternal resurfacing when it is folded. Schipper et al. alsoused a piece of linear-shaped costal cartilage for pre-fabrication.13 They applied split-thickness skin grafts to thedeep surface of the forearm flap for the internal lining,which may cause concerns about long-term contractureand obstruction of the neotrachea. Although the ideal tis-sue for the lining would be mucosa, similar to that of thenative trachea, a well-vascularised reconstructive cutane-ous lining might resist infection, prevent wound contrac-tion, and clear secretions. Our method is even suitable inareas that have experienced previous surgery or irradiation.This flap is an attractive option for the reconstruction oflarge tracheal and skin defects.

References

1. Grillo HC. Tracheal replacement: a critical review. Ann ThoracSurg 2002;73:1995e2004.

2. Matloub HS, Yu P. Engineering a composite neotrachea in a ratmodel. Plast Reconstr Surg 2006;117:123e8.

3. Omori K, Nakamura T, Kanemaru S, et al. Regenerativemedicine of the trachea: the first human case. Ann Otol RhinolLaryngol 2005;114:429e33.

4. Bozkurt AK, Cansiz H. Tracheal reconstruction with autogenouscomposite nasal septal graft. Ann Thorac Surg 2002;74:2200e1.

5. Kobayashi M, Fukuda A, Onozuka N, et al. Design of a new tech-nique using a free tracheal autologous graft for reconstructionof the cricoid cartilage and trachea. Surg Today 2006;36:316e20.

6. Brown BL, Kern EB, Neel 3rd HB. Transplantation of fresh allo-grafts (homografts) of crushed and uncrushed cartilage andbone: a 1-year analysis in rabbits. Laryngoscope 1980;90:1521e33.

7. Shinohara H, Yuzuriha S, Matsuo K, et al. Tracheal reconstruc-tion with a prefabricated deltopectoral flap combined withcostal cartilage graft and palatal mucosal graft. Ann PlastSurg 2004;53:278e81.

8. Nakahira M, Nakatani H, Takeuchi S, et al. Safe reconstructionof a large cervico-mediastinal tracheal defect with a pectoralismajor myocutaneous flap and free costal cartilage grafts. AurisNasus Larynx 2006;33:203e6.

9. Teng MS, Malkin BD, Urken ML. Prefabricated composite freeflaps for tracheal reconstruction: a new technique. Ann OtolRhinol Laryngol 2005;114:822e6.

10. Olias J, Millan G, da Costa D. Circumferential tracheal recon-struction for the functional treatment of airway compromise.Laryngoscope 2005;115:159e61.

11. Beldholm BR, Wilson MK, Gallagher RM, et al. Reconstruction ofthe trachea with a tubed radial forearm free flap. J ThoracCardiovasc Surg 2003;126:545e50.

12. Yu P, Clayman GL, Walsh GL. Human tracheal reconstructionwith a composite radial forearm free flap and prosthesis. AnnThorac Surg 2006;81:714e6.

13. Schipper J, Ridder GJ, Maier W, et al. Laryngotracheal recon-struction using prefabricated and preconditioned compositeradial forearm free flaps: a report of two cases. Auris NasusLarynx 2007;34:253e8.