LAUSR

Dear Editor, Successful free-flap reconstruction is enhanced by frequent monitoring, rapid detection, and salvage of failing flaps (Lin, Chen, Chen, & Tzeng, 2014). However, it is difficult to monitor the buried flaps, leading to a threefold increase in flap loss compared with nonburied flaps (Kim & Kim, 2013). Externalizing a part of the buried flap for monitoring is a practical solution. Troublesomely, unnecessary take-backs can be triggered by the false positive signals (Kim & Kim, 2013; Tan et al., 2012; Yu & Robb, 2005). To minimize this error, we report a modified strategy by externalizing double skin paddles of a buried anterolateral thigh flap in pharyngoesophageal reconstruction. A 58-year-old man underwent oncological laryngopharyngectomy, leaving an 8 cm × 6 cm pharyngoesophageal defect. We harvested a left anterolateral thigh skin flap measuring 22 cm × 6 cm based on 3 cutaneous perforators, and we modified it into a bi-paddle design. The proximal 16 cm × 6 cm skin paddle based on the proximal 2 perforators comprised 3 components: an 8 cm × 6 cm proximal component for pharyngoesophageal reconstruction, a 4 cm × 6 cm mid-component de-epithelialized for the pharyngeal-skin junction, and a 4 cm × 6 cm distal component for externalized monitoring. The distal 6 cm × 3 cm skin paddle based on the distal perforator was used as a second externalized monitor (Figure 1A). Before the division of the vascular pedicle at the donor site and after microanastomosis of the vascular pedicle at the recipient site, both skin paddles showed evident dermal bleeding. The 2 externalized paddles were incorporated into the neck wound (Figure 1B). On postoperative day 1, circulation compromise was noted in the proximal monitoring skin paddle, but the second monitoring skin island maintained good perfusion