The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes

Background: There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects.

Methods: A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates.

Results: Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013).

Conclusions: The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.