Defining the Role of Free Flaps for Transoral Robotic Surgery

Background: Transoral surgical techniques for oropharyngeal tumors have been widely accepted, yet often results in a significant functional deficit. Current reports on the safety, feasibility, and swallowing performance after microvascular reconstruction are limited to small volume case series. Materials and Methods: Retrospective review of 42 consecutive patients, between December 2013 and May 2016, who underwent transoral robotic surgery oropharyngectomy followed by microvascular reconstruction. Results: Swallowing outcomes postoperatively resulted in 39 (93%) of patients tolerating oral intake postoperatively, with 13 (87%) of 15 patients at 1-year follow-up consuming an entirely oral diet. Thirty-eight (95%) of 40 patients who underwent a tracheostomy at the time of surgery were ultimately decannulated. No patients experienced complete flap failure in the current study. Conclusions: Minimally invasive transoral surgical techniques have offered the opportunity to minimize surgical morbidity and potentially deintensify adjuvant therapies. Reconstructive options have evolved to match surgical advances seen with robotic surgeries of oropharyngeal cancers. Microvascular reconstruction has been indicated in select patients including those with extensive soft palate resection, primary tumor abutment of the medial pterygoid musculature, exposure of internal carotid artery vasculature, prior radiation therapy, or a significant defect of the oropharyngeal sphincter. Select patients, based on previously identified criteria, were preoperatively identified as suitable candidates for microvascular reconstruction of oropharyngeal defects. This study demonstrates that complex transoral robotic surgical defects are amenable to microvascular reconstructive in carefully selected patients.