Infrahyoid Myocutaneous Flap for Reconstruction after Robotic Transoral Surgery for Oropharyngeal Tumors

Abstract

Sir: Surgical treatment of oropharyngeal tumor has become less invasive, especially with transoral robotic surgery. As larger resections were performed, the need for minimally invasive reconstruction appeared,1 and the infrahyoid myocutaneous flap has proved to be a reliable alternative to the free flap for reconstructing surgical defects after head and neck surgery.2 We report here our experience with eight cases of infrahyoid myocutaneous flap robotic reconstruction after transoral robotic surgery for oropharyngeal malignancies. Since 2009, eight patients have undergone trans oral robotic surgery for oropharyngeal epidermoid carcinoma associated with immediate reconstruction using an infrahyoid myocutaneous flap. All cases were performed using classical installation for transoral robotic surgery3 with the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, Calif.). After removal of the tumor, a classic complete bilateral neck dissection was performed. The infrahyoid myocutaneous flap was performed conventionally4 and passed into the oral cavity in a minimally invasive way. It was sutured either completely or partially with the robotic instrumentation (Fig. 1). A postoperative tracheotomy was used for all patients. All data concerning patients are summarized in Table 1.Fig. 1: Infrahyoid myocutaneous flap for reconstruction of oral defect. Perioperative view after right oropharyngectomy.Table 1: Summary of Preoperative Data; Operative Data; and Anatomical, Oncologic, and Functional ResultsThe criteria analyzed for functional results were oral or enteral diet, swallowing, and speech. Anatomical results were assessed by surgeons. The results are displayed in Table 1. One patient needed a conversion to open cervical surgery because of difficulties of exposure (Table 1). There was no surgical complication except for one patient who needed reoperation for hemostasis at day 2. Mean hospital stay was 18.5 ± 3.9 days (range, 13 to 27 days). Tracheotomy was removed after a mean time of 11 ± 3 days (range, 6 to 15 days). Aesthetic results were good (Fig. 2).Fig. 2: Aesthetic result, 2 months after reconstruction of an oral defect.Three patients had positive margins; the first patient underwent reoperation at day 28 and the two others were treated with adjuvant radiochemotherapy. One patient had a late locoregional recurrence after 10.4 months. One patient died 2 years after surgery from an unrelated cause; seven other patients were alive and disease-free after a mean follow-up of 21.2 months (Table 1). All patients had postoperative speech therapy, and oral feeding was introduced after 5 days. Postoperatively, one patient had complete enteral feeding with gastrostomy. Three patients had oral feeding and enteral feeding with gastrostomy. Four patients had complete oral feeding (Table 1). This small study highlights good results with infrahyoid myocutaneous flap reconstruction after robotic oropharyngectomy. These results demonstrate the possibility of robotically suturing the infrahyoid myocutaneous flap. The infrahyoid myocutaneous flap has many advantages in transoral robotic surgery: it is highly reliable and easy to perform,4 and it can be placed in the oral cavity by a minimally invasive approach. The long pedicle allows surgeons to use it for many oropharyngeal reconstructions. Its thickness is useful in the small field of view of transoral robotic surgery. The use of transoral robotic surgery is growing rapidly.5 Its widespread use is still limited by the size of the resection. Most authors recommended transoral robotic surgery only for T1 and T2 tumors. Use of the infrahyoid myocutaneous flap could help to develop indications for transoral robotic surgery, in particular, for larger malignancies (T3) with the benefit of relatively high preservation of function after transoral robotic surgery. ACKNOWLEDGMENT The authors thank Marie-Laure Lacave, speech therapist of the Head and Neck Surgery Unit, Institut de Cancérologi