Background
Reconstruction of circumferential hypopharyngeal defects in head and neck cancer patients presents a significant challenge due to various factors. Several documented techniques involve free flap reconstruction to address the hypopharyngeal defect. One such technique is the inverted-omega ALT flap design, which was introduced for simultaneously reconstructing circumferential hypopharyngeal and neck skin defects in one stage. In this study, we present the long-term outcomes of patients who had complete hypopharyngeal defects and underwent free flap reconstruction with this design.

Methods
This study was conducted retrospectively on a cohort of head and neck cancer patients who had circumferential hypopharyngeal defects and had undergone free flap reconstruction between January 2013 and October 2023. Our primary objective was to identify patients who had used the design of an inverted-omega ALT flap. We recorded the clinical data and outcomes of these patients.

Results
Eleven patients with circumferential hypopharyngeal defects who underwent the inverted-omega ALT flap reconstruction were collected. The pathologic diagnoses were primary or recurrent squamous cell carcinoma in the supraglottic or hypopharynx. All patients underwent preoperative neoadjuvant concurrent chemo-radiotherapy (CCRT).
The average flap size was 218 cm2 (range: 120~450 cm2). Seven flap donor site was closed by skin graft, and four were primarily closed. All flaps survived. The fistula rate was 63.6% (7/11). 2 fistulas healed by secondary healing; four fistulas healed after the surgical intervention, and one fistula needed a loco-regional flap for secondary reconstruction.

Conclusion
For the circumferential hypopharyngeal defect, this inverted-omega ALT flap tubing design is a feasible option. However, the incidence of fistula is relatively high, and the donor site often requires skin grafting surgery. Additional deliberation and contemplation are needed in its application.

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