SPECIAL TOPIC Reconstruction of the Esophagus and Voice Samir Mardini, M.D. Christopher J. Salgado, M.D. Karen F. Kim Evans, M.D. Hung-Chi Chen, M.D. Rochester, Minn.; Taiwan, Republic of China; and Washington, D.C. Background: Esophageal defects are reconstructed using a variety of methods and tissue types. The choice depends on the location of the defect, the condition of the patient, and the flaps that are available for reconstruction. Often, patients with esophageal defects also lack a mechanism for voice production following a total laryngectomy procedure. Methods: A review of the literature was performed for esophagus reconstruc- tion and voice rehabilitation following laryngectomy. Methods of voice resto- ration using intestinal transfers are presented based on the authors’ experience. Results: Several methods of esophagus and voice restoration can achieve ex- cellent functional outcomes. Conclusion: Esophagus reconstruction and voice rehabilitation following esophageal resection and total laryngectomy are possible using a variety of flaps with good functional outcomes. (Plast. Reconstr. Surg. 126: 471, 2010.) T he advent of microsurgical techniques and advances in understanding of flap surgery have allowed for the successful reconstruc- tion of complex defects involving the hypophar- ynx, cervical esophagus, and voice mechanisms in a single-stage operation with minimal complications. 1,2 In the past, multiple staged procedures were per- formed to reconstruct hypopharyngeal and esoph- ageal defects, which ultimately resulted in some successes 3 ; however, many procedures were re- quired, hospitalization times were longer, and im- mediate and long-term complications and poor functional outcomes were met. In patients in whom conventional methods were exhausted and all attempts had failed, a gastrostomy or jejunos- tomy was placed for nutrition. Microsurgical ad- vances over the past four decades have allowed for completion of reconstruction of almost all types of esophageal defects. 4 Indications for esophagus re- construction, with or without voice reconstruc- tion, are congenital disease, tumor excision, radi- ation damage, a failed reconstructive effort, or corrosive injury. The defect may be partial or com- plete (circumferential), and may involve a short or long segment. A complete circumferential defect involving the hypopharynx and/or cervical esoph- agus is typically encountered following tumor ex- cision. Complete circumferential defects can ex- tend from the pharynx to the pylorus. 5 When total laryngectomy is performed with or without esophageal resection, the patient is left with the catastrophic predicament of the lack of a mechanism for voice production. The ultimate goal in performing reconstruction in these pa- tients is to establish a continuous gastrointestinal tract, using a functional conduit, and create a mechanism for voice production in patients who have undergone total laryngectomies. The hope is that these patients will be able to eat without choking, nourish themselves through oral in- take alone, and be able to produce intelligible speech through one of the available mecha- nisms that are discussed below. The anatomical defect dictates the type of re- construction that should be used. 6 Therefore, one must clearly understand the normal anatomy (Fig. 1) and physiology of the upper gastrointestinal tract and the voice production mechanisms. The options available for hypopharyngeal and esophageal reconstruction range from placing a skin graft over a stent, to local and regional flaps that are pedicled (local random pattern skin flaps, deltopectoral flap, or pectoralis major flap), re- gional pedicled intestinal flaps (stomach, colon, From the Division of Plastic Surgery, Mayo Clinic; Depart- ment of Plastic Surgery, E-Da Hospital/I-Shou University; Division of Reconstructive Surgery, Veterans Affairs Medical Center; and Department of Plastic Surgery, Georgetown Uni- versity Medical Center. Received for publication September 30, 2007; accepted Jan- uary 27, 2010. Copyright ©2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181de2348 Disclosure: The authors have no commercial asso- ciations that might pose or create a conflict of inter- est with the information presented in this article. www.PRSJournal.com 471