For laryngeal cancer patients presenting after radiation therapy, there is a significantly higher risk of mucosal leak that occur from the laryngectomy closure.  Furthermore, if you force remaining pharyngeal lining to close up primarily, it will result in severe esophageal stenosis that will result in severe dysphagia and unable to tolerate regular food.  Studies have shown that if you use non-radiated vascularized flap, there is a significantly lower rate of complications in radiated total laryngectomy patients.

More commonly, we will consider using radial forearm free flap for the preferred vascularized flap for total laryngectomy.  In this case, patient had abnormal Allen’s test and his wrist tissue was too thin.  As such, ALT flap was used instead as an alterative option.

Key to avoiding complications with total laryngectomy patients are following:

1) not developing a fistula from pharyngeal closure. To achieve this, mucosal lining and epithelial lining must be inverted into the esophageal lumen.

2) breakdown adjacent to the stoma can lead to direct carotid artery exposure and carotid blowout.  It is imperative that bilateral carotid artery are covered.  In this case, we had significant muscle from ALT that was used to drape over the carotid artery along the posterolateral aspect of the stoma.  In situations where you are not using ALT flap or in routine total laryngectomy (pre-radiation), you can disinsert clavicular head of SCM bilaterally.  The clavicular head of the SCM can then be mobilized and attached to the posterolateral corner of the stoma. This portion of the SCM will cover the carotid artery superficially so if you get a skin break down, you won’t have direct exposure of the carotid artery