S4323 From Dermis to Digestive Tract: When Skin Flaps Do More Than Expected

Introduction: Esophageal reconstruction following laryngeal cancer surgery often involves autologous tissue grafts, such as skin flaps from the thigh. While these flaps provide structural integrity, they may retain characteristics of their original tissue, potentially leading to unexpected complications. This report aims to document an unusual complication of esophageal reconstruction with a thigh skin flap, specifically growth of hair within the esophagus, which can contribute to recurrent food impactions. Case Description/Methods: An 84-year-old man with a history of laryngeal cancer (ypT0N0M0 - treated with neoadjuvant radiation, followed by surgical resection and reconstruction with autologous free flap and tracheostomy) presented to the emergency department with food impaction in his throat. He had a known history of prior food impactions, often resolving with consumption of carbonated drinks or administration of glucagon. However, in this instance, these measures were unsuccessful, necessitating further intervention. Patient has undergone esophageal dilations in the past due to strictures. The patient underwent a computed tomography scan, which revealed a 3.9 cm food bolus in the mid-cervical esophagus. He was unable to swallow his saliva necessitating an emergent esophagogastroduodenoscopy. This revealed hair growth in the esophageal mucosa from 7 cm to 20 cm distal to the incisors, leading to food bolus retention. The food bolus was successfully removed using rat-tooth forceps. No esophageal stricture was observed, and the scope was easily passed into the stomach which showed moderate gastritis and multiple non-bleeding duodenal ulcers. Discussion: Reconstruction of the esophagus using autologous skin flaps is a common technique following extensive surgical resection for malignancy. However, the persistence of adnexal structures such as hair follicles and sebaceous glands in these grafts can result in complications such as hair growth within the esophageal lumen. While hair growth in esophageal reconstructions using skin flaps is rare, it is a recognized occurrence. The presence of hair can lead to friction, irritation, and food adherence, increasing the risk of obstruction. Management options may include endoscopic removal of hair or debridement, repeated esophageal dilations, laser or electrocoagulation therapy and surgical revision. Awareness of this phenomenon is crucial for clinicians managing patients with post-reconstruction dysphagia.