Reply: Optimizing Outcomes in Pharyngoesophageal Reconstruction and Neck Resurfacing

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I thank the authors for their thoughtful commentary concerning the role of the internal mammary artery perforator flap in neck resurfacing during pharyngoesophageal reconstruction. The flap is a versatile and useful reconstructive technique, and Salgarello et al. have nicely summarized the anatomy, the technical considerations, and the advantages. Although I agree with most of their comments, I would like to add some additional considerations. In my experience, the vertical orientation of the internal mammary artery perforator flap, which is required to transpose the tissue above the sternal notch, may not be ideal for resurfacing. In most such cases, the skin requirement is along the entire length of the transverse wound; therefore, a transverse, elliptical shaped skin island is optimal. I agree that the first-line option is a second skin island from the anterolateral thigh flap, which can be easily oriented in the transverse dimension, as long as the second perforator has been fully dissected for independent movement. When a second skin island from the anterolateral thigh is unavailable due to absence or insufficient perforator size, a simple solution is the vastus lateralis muscle with a skin graft. This has the advantage of providing a large amount of vascularized tissue from the same vascular axis. The primary disadvantage of this approach is that because it requires a skin graft, it is cosmetically less desirable than a second skin island. A two-paddle, forearm-based flap is certainly second line, and in general should only be used for small defects, usually an anterior pharyngeal patch rather than a circumferential defect, or in cases when the anterolateral thigh is too thick to effectively tube.
When a second independent source of skin is sought for resurfacing, the supraclavicular flap is another excellent alternate option. The perforator that supplies this flap, originating from the transverse cervical vessels, emerges above the clavicle at the level of the cricoid, positioning it well for a transverse skin island. In our hands, the internal mammary artery perforator flap is lower on the algorithm for neck resurfacing than the supraclavicular flap, because of the vertical orientation and because much of the internal mammary artery perforator is lost covering the distance from the chest to the neck. In addition, the trachea stoma lies in the path of the flap as it traverses the sternal notch and can get in the way of flap positioning, a problem the authors have pointed out can also occur when using the pectoral flap.
I do consider the internal mammary artery perforator flap as the first-line option for wounds related to break down or revisions of the trachea stoma. This can occur as a result of delayed wound healing of the surrounding skin, which is often radiated and dysvascular, or a pharyngocutaneous fistula that communicates directly with the stoma. In these cases, the internal mammary artery perforator flap lies in an ideal position for stomal revision. It is thin, pliable, and sensate, as the authors of the commentary have highlighted, and rarely leads to stomal obstruction or difficulty fitting a laryngectomy tube.
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