CASE REPORT

Cricotracheal reconstruction with free radial forearm flap and titanium mesh

Deepak Balasubramanian, MS, Krishnakumar Thankappan, MCh, Sharankumar Shetty, MS, Kiran Jayaprasad, MS,Jimmy Mathew, MCh, Subramania Iyer, MD, FRCS*

Department of Head and Neck and Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Accepted 15 November 2011

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.22931

ABSTRACT: Background. Reconstruction after partial cricotrachealresection is technically demanding and is seldom reported in literature.The purpose of this study was to report a technique of reconstruction ofsuch a defect with a radial forearm flap supported by a titanium mesh.

Methods. A 75-year-old man who was diagnosed with a case ofpapillary carcinoma thyroid, underwent excision of the tumor with apartial cricotracheal resection. The defect was reconstructed with afree radial forearm flap with fascia suspended on a titanium mesh.

Results. At a follow-up of 6 months after treatment, the patient hasnormal nasal breathing and an acceptable voice.

Conclusion. This reconstructive technique enabled us to maintainthe integrity of the subglottic airway. Our technique was unique inthat we used the skin-lined part of the radial forearm flap to line theairway and the fascia to cover the titanium mesh outside, therebypreventing plate exposure. VC 2012 Wiley Periodicals, Inc. Head Neck00:000-000, 2012

KEY WORDS: cricotracheal reconstruction, free radial forearm flap,head and neck cancer, thyroid cancer, tracheostomy

INTRODUCTIONThe larynx is composed of a cartilaginous framework

and subserves the important functions of breathing andvoice production. The cricoid cartilage of the larynx isunique in that it is the only complete ring in the frame-work and its integrity is essential in maintaining the sub-glottic airway. Thyroid malignancies invading the laryn-geal cartilages will necessitate a laryngectomy for surgicaldisease clearance. Herein, we present a case of papillarycarcinoma thyroid with involvement of the cricoid and tra-cheal cartilages where a partial cricotracheal resection wasdone. The resultant defect was reconstructed with vascular-ized radial forearm flap suspended on a titanium mesh.This reconstructive technique enabled us to maintain theintegrity of the subglottic airway and allowed the patientto preserve his voice and nasal breathing.

CASE REPORTA 75-year-old man presented with swelling in the left

lower neck and hemoptysis for 3 months duration. Hewas previously diagnosed with papillary carcinoma thy-roid and had undergone total thyroidectomy 10 yearsprior. After surgery, he had also undergone radioiodineablation twice. A CT scan revealed a heterogeneouslyenhancing lesion in the thyroid bed on the left side meas-uring 3.1 � 3.5 � 4.6 cm (Figure 1). There was infiltra-tion of the cricoid lamina and the tracheal lumen. A flexi-

ble endoscopic evaluation showed a smooth bulge in theanterior subglottis. The case was discussed in a multidis-ciplinary tumor board and it was decided to surgicallyremove the disease with adjuvant radioiodine ablation andexternal beam radiation therapy (EBRT). During surgery,there was a firm mass in the left tracheoesophagealgroove involving the cricoid cartilage, the lower end ofthe thyroid cartilage on the left side, and the upper 5 tra-cheal rings. A frozen section examination of the massconfirmed the diagnosis of papillary carcinoma thyroid.The mass was excised completely. The left recurrent la-ryngeal nerve was involved by tumor and had to beremoved. The defect in the trachea measured 6 cm inlength and involved part of the cricoid cartilage and upper4 tracheal rings. The width was 3 cm on the cricoid areaand 2 cm over the trachea (Figure 2). A free radial arteryforearm flap with a facial extension was harvested fromthe hand (Figure 3). The titanium mesh was fabricated as2 pieces of 5 cm in length and 2 cm in breadth over thecricoids area and 4 cm in length and 2 cm in breadthover the trachea, respectively. These were bent to assumethe cricotracheal curvature and were anchored to the car-tilages using polypropylene sutures. A gap of 1 cm wasleft between the rings. The skin part of the radial forearmflap was sutured with the skin surface facing inwardalong the edges to get an airtight seal (Figure 4). The fas-cia from the distal part of the radial forearm flap wasnow flipped over to cover the mesh on its superficial sur-face and anchored to the surrounding tissues (Figure 5).The arterial anastamosis was done to the superior thyroidartery and the vein to the external jugular vein. The skinclosure was then carried out in layers. A tracheotomy was

*Corresponding author: S. Iyer, Department of Head and Neck and Plastic andReconstructive surgery, Amrita Institute of Medical Sciences, Kochi, India.E-mail: subu@aims.amrita.edu

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done inferior to the defect. The patient recovered well.The patient was able to speak and breathe through hisnose after closing the tracheostomy tube. The voice was

hoarse due to the left vocal cord palsy. The patient under-went Iodine-131 ablation 6 weeks postsurgery. Subse-quently, he underwent EBRT with intensity-modulated

FIGURE. 1. Coronal CT showing the extent of the extent of tumorand involvement of cricoid cartilage.

FIGURE. 2. Intraoperative photograph showing the cricotrachealdefect. [Color figure can be viewed in the online issue, which isavailable at wileyonlinelibrary.com.]

FIGURE. 3. Flap marking on the patient hand: distal marking isfor the fascia and the more proximal marking for the skin paddle.[Color figure can be viewed in the online issue, which is availableat wileyonlinelibrary.com.]

FIGURE. 4. Intraoperative photograph showing the titaniummesh fixed on the cartilage and the flap being inserted. [Colorfigure can be viewed in the online issue, which is available atwileyonlinelibrary.com.]

FIGURE. 5. Final intraoperative photograph after the fascia hasbeen sutured over the mesh. [Color figure can be viewed in theonline issue, which is available at wileyonlinelibrary.com.]

FIGURE. 6. Postoperative scopy showing adequate glottic spaceand the skin lined flap in the subglottic space. [Color figure canbe viewed in the online issue, which is available atwileyonlinelibrary.com.]

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Balasubramanian et al.

radiation therapy delivering 60 Gy in 30 fractions. Thetracheotomy tube was retained until the planned EBRTwas completed. The flap healed well in the infraglotticarea (Figure 6). The soft tissue neck X-ray showed agood and adequate airway (Figure 7). The patient wasdecannulated 2 months after the completion of radiation.The total duration of the tracheostomy was 5 months. Sixmonths after surgery, the voice was satisfactory buthoarse due to persistent left vocal cord palsy. The patientwas taking a regular oral diet, and his breathing was nor-mal. The patient was able to climb 2 flights of stairswithout effort.

DISCUSSIONLaryngotracheal invasion by thyroid cancers is an inde-

pendent prognostic factor for survival.1 Resections of thelarynx and trachea improve the survival in invasive thy-roid cancers.2 The cricoid cartilage is unique in that it isthe only complete ring in the laryngotracheal system. Theintegrity of the cricoid cartilage is essential in maintain-ing a patent airway. Resections of part or whole of thecricoid leave the surgeon with few options for reconstruc-tion. Isolated tracheal reconstruction has been reported inliterature.3-6 However, combined cricotracheal reconstruc-tion has been seldom reported. Yu et al7 reported recon-struction after combined cricotracheal resection using aradial forearm free flap with a combined PolyMax resorb-able mesh(Synthes, Paolin, PA) and Hemashield vascular

graft (Boston Scientific, Natick, MA). The present tech-nique differed in that we used titanium plates for the rigidsupport that was covered internally by the skin of the flapand externally using the fascia. The fascia covering theplates externally provided adequate bulk and preventedplate exposure. The use of the titanium plate has beenreported by Liu et al8 in the reconstruction of laryngealdefects after vertical partial laryngectomies. Their tech-nique did not include a free flap to cover the mesh.Instead, they used the sternohyoid muscle to surface theinner aspect of the mesh and the omohyoid muscle tocover the outer aspect of the mesh. A free flap allowsmore precise reconstruction with a resilient skin liningto the inner airway. A drawback of this report is that6-month follow-up is a short time for tracheal recon-struction with a titanium mesh as supporting materialfollowed by EBRT. The potential risk of erosion exter-nally or internally by the metal mesh after radiationremains, although there are no such signs at the end ofthe follow-up.

CONCLUSIONCricotracheal reconstruction is possible using a combi-

nation of radial artery free flap and a titanium mesh. Thecombination provided a competent adequate airway and acompletely covered rigid mesh. The chances of plate ex-posure are minimized with this technique.

REFERENCES1. Czaja JM, McCaffrey TV. The surgical management of laryngotracheal

invasion by well-differentiated papillary thyroid carcinoma. Arch Otolaryn-gol Head Neck Surg 1997;123:484–490.

2. Gaissert HA, Honings J, Grillo HC, et al. Segmental laryngotracheal andtracheal resection for invasive thyroid carcinoma. Ann Thorac Surg 2007;83:1952–1959.

3. Friedman M. Surgical management of thyroid carcinoma with laryngotra-cheal invasion. Otolaryngol Clin North Am 1990;23:495–507.

4. Ashford BG, Clark JR. Cricotracheal reconstruction following externalbeam radiotherapy for recurrent thyroid cancer. ANZ J Surg 2009;79:271–274.

5. Fujiwara T, Nishino K, Numajiri T. Tracheal reconstruction with a prefabri-cated and double-folded radial forearm free flap. J Plast Reconstr AesthetSurg 2009;62:790–794.

6. Maciejewski A, Szymczyk C, P�ołtorak S, Grajek M. Tracheal reconstruc-tion with the use of radial forearm free flap combined with biodegradativemesh suspension. Ann Thorac Surg 2009;87:608–610.

7. Yu P, Clayman GL, Walsh GL. Human tracheal reconstruction with a com-posite radial forearm free flap and prosthesis. Ann Thorac Surg 2006;81:714–716.

8. Liu XK, Zhang Q, Li Q, et al. Laryngeal framework reconstruction using ti-tanium mesh in glottic cancer after frontolateral vertical partial laryngec-tomy. Laryngoscope 2010;120:2197–2202.

FIGURE. 7. Postoperative lateral neck X-ray showing adequateairway.

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Cricotracheal Reconstruction with Free Flap and Mesh