High-Voltage Electrical Injury Causing a Full-Thickness Laryngotracheal Wall Defect: Reconstruction With an Anterolateral Thigh Free Flap and an Inverted Split-Thickness Skin Graft.

Full-thickness loss of the laryngotracheal wall is a rare and severe consequence of high-voltage electrical injury. It is anatomically and clinically distinct from the epithelialised tracheocutaneous fistula that follows tracheostomy decannulation, and it poses a far greater reconstructive problem because of progressive tissue necrosis, wound contamination, and exposure of the airway and major cervical vessels. We report the case of a 30-year-old man with approximately 30% total body surface area deep electrical burns involving the neck, abdomen, and all four limbs, who presented with an exposed airway and exposed major cervical vessels. After resuscitation and staged debridement, a full-thickness defect of the anterior and left anterolateral laryngotracheal wall was identified, extending from the cricoid to the fourth tracheal ring, with the glottis and vocal cords uninvolved and the membranous posterior wall intact. Reconstruction was performed on day 49 after injury with an inverted split-thickness skin graft as luminal lining, its raw surface applied to the deep fascia of a left anterolateral thigh (ALT) free flap anastomosed to the left transverse cervical vessels. An 18 Fr Foley catheter was left transnasally across the reconstructed segment as a through-and-through stent. No cartilage support was used. The postoperative course was uneventful, with complete flap survival, no recurrence of infection, and no fistula formation. Airway support was withdrawn in stages: extubation on the day of surgery, stent removal on postoperative day 14, and removal of the tracheostomy tube on postoperative day 21, after which the patient breathed through the reconstructed segment and his native upper airway alone. At six months, he had normal swallowing, near-normal speech, and 50 degrees of neck extension, with no stridor or exercise limitation; bronchoscopy, cross-sectional imaging, and formal voice assessment were not performed. In this single patient, an ALT free flap combined with an inverted split-thickness skin graft was a feasible option for a large laryngotracheal wall defect after severe electrical burn. Longer follow-up with objective assessment of airway patency and further cases are required before durability and reproducibility can be established.