Defect size

Reconstruction

Pros

Cons

pharyngeal mucosal width remaining

> 3.5 cm

Primary closure [1]

simple

Risk of stricture

< 3.5cm and > 1cm

Pectoralis major myocutaneous pedicle flap

Reliable.

Versatile workhorse flap.

Resistant to radiotherapy.

Donor site co-morbidity. Bulkiness

Radial forearm free flap

Thin.

Long pedicle

Donor site poor cosmetic appearance.

Colour mismatch. Hair bearing skin Complex procedure

< 1cm

Completion circumferential

reconstruction

Circumferential defect

Lower anastomosis above the clavicle

Free Jejunal transfer

Useful in case the pulled-up stomach cannot reach the Pharynx

Laparotomy required Anastomosis stricture Swallowing problems due to hyperperistalsis.

Wet sounding voice

Gastro omental free flap

Anastomosis stricture Requires laparotomy Complex procedure. Marked comorbidities

Tubed radial forearm free flap.

Tubed ALT

Long pedicle Thin flap

Better if tubed over a salivary bypass

Large skin/fascia paddle

Long pedicle Thin flap

High rate of leakage and stricture.

Poor function (swallowing & speech) Hair bearing skin

Colour mismatch Donor site comorbidity

Poor function (swallowing & speech) Hair bearing skin

Colour mismatch

Previously untreated cases

Tubed ALT over a salivary bypass tube

Advantages of ALT plus lowest rate of leakage and stenosis with more satisfactory voice and swallow function

rehabilitation

Post chemo/radiotherapy (Salvage) Procedures

GFFs

Additional Free flap (ALT)

Omentum can be wrapped around the anastomosis to decrease risk of leakage and fistula

Resurface the skin in case of extensive radiotherapy

damaged skin

Requires laparotomy Marked comorbidities Complex surgery

Complex surgery Prolonged theatre time

Circumferential defect

Lower anastomosis below the clavicle

Gastric pull through

Colonic transposition flap

Higher reach Can reach oropharynx

5-15% mortality

30-55% morbidity

3-23% fistula rate

Pharyngeocutaneous fistula (PCF)

Vascularized tissue transfer from outside the irradiated area

Sandwich technique

Decreased PCF rate from 30% by half

Manage resistant PCF

Additional surgical procedure

Small to medium size defects

Submental flap

Reliable

Minimal donor site morbidity

Non complicated procedure

Not suitable for larger defects

May be not feasible if post radiotherapy