Reconstruction after salvage total laryngectomy

Over recent decades, there has been a trend toward non-surgical or “organ preservation” therapy for advanced staged laryngeal cancers, but up to 1/3 of patients will see a lack of long-term treatment response. As a result of this paradigm shift, total laryngectomy is increasingly performed in the ‘salvage’ setting. Salvage total laryngectomy is associated with high rates of complications from impaired wound healing from prior chemotherapy and/or radiotherapy, and reconstructive techniques aim to decrease these complications. Regional and free tissue flaps are used in contemporary reconstruction of salvage laryngectomy defects. In this article, the pectoralis major myocutaneous flap and the anterolateral thigh fasciocutaneous free flap are discussed in detail. Additionally, specific techniques are described in a defect-based approach with special attention to total laryngectomy with primary closure of the mucosa, as well as defects not amenable to primary closure, such as total laryngectomy with partial or total pharyngectomy and esophagectomy. This defect-based approach allows the author to present surgical scenarios commonly encountered during salvage total laryngectomy and walk the reader through various reconstructive techniques.