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Zühtü Demir, M.D., Hifzi Velidedeoglu, M.D., and Selim Çelebioglu, M.D. ˘ ˘
Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, débridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 3 cm and the minimum size was 4 2 cm (average, 4.8 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donorsite morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed. (Plast. Reconstr. Surg. 115: 38, 2005.)
After surgery for conditions such as laryngeal cancer or hypopharyngeal cancer, salivary pharyngocutaneous fistulas are sometimes troublesome complications. In the literature, the frequency of fistula formation varies from 2 to 66 percent.1–3 Patients suffer considerable prolonged morbidity including salivary leakage, protracted difficulties in deglutition, and delay in postoperative irradiation when indicated. In general, these problems occur in patients who are compromised by malnutrition, advanced disease, ischemic tissues secondary to irradiation, and infection. The management of these fistulas is a challenge for the surgeon and patient. Although most fistulas are small and heal spontaneously, larger fistulas require surgical reconstruction. The surgical reconstruction requires imagination and technical skill. A number of methods to close such pharyngocutaneous fistulas are available. Myocutaneous and free flaps have become the standard of care for these fistulas. However, each of these techniques has its drawbacks.4 The submental island flap, an axial pattern flap first introduced by Martin et al. in 1993,5 is a reliable source of skin in the reconstruction of various head and neck defects. We have used this flap for closing pharyngocutaneous fistulas that have been created at or developed after surgery. In this report, we present our clinical experience with use of the submental artery island flap for the reconstruction of pharyngocutaneous fistulas.
We have repaired nine pharyngocutaneous fistulas using the submental island flap in the past 4 years. All patients were men and had
From the Department of Plastic and Reconstructive Surgery, Social Security Foundation Ankara Research Hospital. Received for publication August 29, 2003; revised January 26, 2004. DOI: 10.1097/01.PRS.0000145941.51938.67
After 4 weeks. and the submental vessels can now be dissected back to the facial vessels. right). Dilute barium radiography performed 3 weeks after the operation showed normal continuity of the upper digestive tract in all patients. a 2. above. 115. Three weeks postoperatively. This closure can be tested by having the patient swallow either methylene blue or grape juice. Venous congestion was observed on the second postoperative day in only one flap and subsided spontaneously. First.Vol. 1. There were no problems with the marginal mandibular branch of the facial nerve. A 3 5-cm submental island flap was planned and elevated on the right side submental vessels (Fig. Technique Six patients were operated on under local anesthesia with sedation. CASE REPORTS Case 1 A 73-year-old man had previously undergone laryngectomy. The maximum flap size was 6 3 cm and the minimum size was 4 2 cm (average. The others were operated on under general anesthesia. The detailed anatomy of the submental island flap is presented elsewhere. The flap is then tunneled to the recipient site to the second layer closure.5–11 The upper limit of the flap is marked just under the mandibular arc to avoid a visible scar. The TABLE I Patient and Flap Data Patient Age (yr) Primary Lesion Flap Size (cm) Complications Postoperative Stay (days) Oral Intake Days Follow-Up Duration (yr) 1 2 3 4 5 6 7 8 9 61 57 73 62 68 72 58 75 59 Larynx Larynx Larynx Larynx Larynx Larynx Larynx Larynx Larynx 5 4 5 6 4. and the patient was started on a clear liquid diet.5 6 4 5 4 3 3 3 3 3 3 2 2 3 None None None None None None None None None 1 2 1 1 1 3 1 2 1 22 21 23 22 24 23 22 21 24 4 4 3 3 3 2 1 1 1/2 . The patients underwent total laryngectomy and developed a salivary pharyngocutaneous fistula after operation. Two case reports are presented. 4. no major complication was noted and satisfactory results were obtained. Dissection can be carried down to the origin of the facial vessels to achieve a long pedicle. an elliptical flap around the fistula is designed to repair the inner surface of the pharynx. After incising the borders of the flap. the submental island flap is planned according to the cutaneous defect size. The submental vessels are identified near the inferior border of the mandible on the flap pedicle side. The flap was then passed to the defect through a subcutaneous tunnel for the second layer closure. RESULTS The patients were observed for 6 months to 4 years. The undermined skin edges of the ellipse are then inverted in a trapdoor fashion. below).8 2. 1. a dilute barium radiograph was obtained. The donor site was closed primarily. A skin incision is made around the flap and the tissue is undermined up to the point of the fistula. Pressure dressing and primary repair were attempted in all of the patients. In this way. 1).5 4. A complication of his laryngectomy was a pharyngocutaneous fistula (Fig. There was no evidence of recurrent tumor.7 cm) (Table I). All donor defects were closed primarily. After the inner side watertight closure was performed using the local tissue around the fistula. During this period. The patient is placed in supine position with the head and neck moderately extended. and sutures are placed in the subcutaneous fat to create an inner squamous cell lining. All flaps survived completely. though without success. with careful preservation of the marginal mandibular nerves. the submental artery island flap is created. The flap is then mobilized from the mandible. 57 to 75 years) (Table I). The operation was performed under light sedation and local anesthesia. The mean age was 65 years (range. Once a watertight closure is achieved. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 39 laryngeal cancer that required radiotherapy after laryngectomy. the dissection is carried down through the platysma muscle.5-cm cutaneous defect was created. The donor site closes directly without additional dissection. No. The flap is then elevated in an inferior fashion in the subplatysmal plane. they were placed on a mechanical soft diet. the nasoesophageal feeding tube was removed. (Fig. The postoperative course was uncomplicated.
4. No DISCUSSION Postoperative pharyngocutaneous fistula is a relatively frequent complication of total laryngectomy that prolongs the hospitalization of 2 to 3 weeks to many weeks or even months. right). Case 2 A 68-year-old man suffered from a pharyngocutaneous fistula that occurred immediately after total laryngectomy at another center. a dilute barium radiograph showed a patent upper digestive tract. 4. (Above. right) Skin markings for the elliptical flap around the fistula and submental artery island flap based on the right side submental artery. After closure of the inner surface of the pharynx.9 2. A mechanical soft diet was started in the fourth postoperative week without evidence of fistula or stenosis (Fig. complication was observed in the postoperative period.5 4-cm cutaneous defect was created and a 3 4. patient was discharged from the hospital with continued tube feeding on the first postoperative day.40 PLASTIC AND RECONSTRUCTIVE SURGERY. a mechanical soft diet was started (Fig. and the patient was started on a clear diet (Fig. Four weeks postoperatively. When we first examined the patient. The operative procedure was similar to that used in case 1.5-cm submandibular island flap was raised on the right side submental artery. (Below) Intraoperative view: elevation and transposition of the flap through the subcutaneous tunnel to the recipient site after the inner side closure was performed. center). We decided to use a submental island flap for fistula repair. a 2. 1.3 cm (Fig. 3).1 The cause of pharyngocutaneous fistula formation may be linked directly to local tissue ischemia followed by infection and subsequent wound . January 2005 FIG. 2). left). The flap was passed through a subcutaneous tunnel for second-layer closure. The patient was discharged on the first postoperative day with a nasoesophageal feeding tube. 4. A clear diet was given orally 3 weeks after the operation and no fistula and stenosis was revealed by dilute barium radiography (Fig. Three weeks postoperatively. left) The first patient with pharyngocutaneous fistula before the operation. the fistula measured 0. (Above.
Final results of the first patient. However.17 The Bakamjian flap.1. Early conservative fistula management consists of adequate wound drainage. the important drawback to this procedure is the aesthetic change in the central third of the lower lip. Contributing factors include advanced disease and poor nutritional status.18 Sternocleidomastoid muscle flaps have been used for closure of nonmalignant fistulas.17 However. it is very bulky and is generally indicated in cases of large substance loss in the pharyngolaryngeal area.19. elevated from the deltopectoral region based on an axial vascularization coming from cutaneous branches of the intercostal arteries. pressure dressing. nasogastric feedings.4. débridement and flap closure are indicated.12. the failure rate has remained high and the risk of tissue necrosis after neck dissection and heavy radiation discourages their use. minimal débridement. and lateral cervical flaps have been used.2 When fistulas fail to close with conservative measures.15 Spontaneous closure is expected in approximately two-thirds of these patients.1. The reconstruction requires imagination and technical skill. Radiograph of the normal continuity of the upper digestive tract 3 weeks after the operation. 3.21 Janssen and Thimsen reported the use of a full-thickness flap involving the middle third of the lower lip based on the submental artery for full-thickness closure of cervical esophagocutaneous fistulas. and size and site of tumor has also been found. it usually requires two reconstructive procedures and leaves major aesthetic sequelae.4. FIG.2. Radiotherapy together with wound infection is one of the main causes of this pathologic condition. Surgical treatment is not yet standardized and. as evidenced by decreased serum protein and hemoglobin levels. However. especially in radiation fields.4.4.2. A relationship between fistula formation and neck dissection. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 41 FIG. because of the random pattern vascular supply of these flaps.12–14 Small or medium-size fistulas. rotation and transposition flaps.2. Fabrizio et al.12 reported the use of the fasciocutaneous island flap pedicled on the superficial temporalis artery for the reconstruction . and frequent antibiotic oral swishes to irrigate the fistula. 115. coexisting systemic disease. it is impossible to envisage an ideal solution for repairing complex lesions. especially those who have a small anterior or laterally positioned fistula where the greater portion of the neck wound is healed.2.1.2. No.Vol. antiseptic gauze packing.16 However. frequent use of suction catheters.12. Local procedures such as rhomboid flaps.20 The pectoralis major flap can be used with or without a skin island. 2. breakdown. especially in nonirradiated patients.1.12. Direct closure is not adequate for larger wounds. usually close spontaneously with conservative therapy.17.12.2. has long been the flap of choice for closure of large pharyngocutaneous fistulas. at present.
(Right) Postoperative appearance.17 The free radial forearm flap is a suitable alternative for the reconstruction of pharyngocutaneous fistulas. (Left) Appearance of the patient in case 2. Morbidity of the donor site is another factor for consideration. It supplies an extensive area of the ipsilateral upper neck and a variable area across the midline. we used the submental island flap based on the contralateral site without any problem. The major drawback of this technique is a previous bilateral neck dissection where both of the facial arteries may have been killed. and the vascularity of this flap specifically is so good that we have no hesitation using the flap closure for pharyngocutaneous fistulas in heavily irradiated tissue. However. is clear.12.42 PLASTIC AND RECONSTRUCTIVE SURGERY.. Although problems following division of the radial artery are rare. The blood supply of the skin of the head and neck in general is known to be rich. these procedures can be quite extensive and can involve considerable risk. (Center) Radiograph obtained 3 weeks postoperatively showing the patent upper digestive tract of patient 2. The surgical advantage of an axial flap. the submental artery island flap can be raised on the contralateral side pedicle successfully and inset into the defect. They used a skin graft for donor-site closure.17. 6 months after the operation.22–24 However. Because of rich subcutaneous and subdermal anastomoses between the two submental arteries. the submental artery island flap can be easily raised on one side pedicle successfully and rotated to the whole homolateral face and neck.33–37 The submental artery island flap is very versatile and durable for closure of facial defects.5–10 Using the principles originally described by Martin et al. Other described techniques have to be considered along with the use of free flaps. some cases have been reported. In our five patients with previous ipsilateral neck dissection. who suffered from pharyngocutaneous fistula. in patients who have undergone previous ipsilateral neck dissections. An elliptical flap designed around the fistula was sufficient to repair the inner surface of the . January 2005 FIG. Free intestinal flaps provide the ability to close larger fistulas in a one-stage operation.32 It is also very risky to use microsurgical techniques because of functional and structural alteration of the local vascular pedicles after radiotherapy for adjuvant treatment of head and neck cancer. it may leave a troublesome scar and has its inherent complications. 4. The submental artery is a consistent branch of the facial artery.29 –31 Another major problem with this technique is that it necessitates sacrifice of a major artery to the hand.5 we have repaired pharyngocutaneous fistulas with the submental island flap. of a pharyngocutaneous fistula in a patient. which has a recognizable arterial and venous circulation that the long axis of the flap can follow and which yields branches to the dermal-subdermal plexus.25–28 Because it requires harvesting from a second operative site. which is time consuming.
1985.. G. 20. Laryngol. Otol. A.11 In patients with larger fistulas in which the skin around the fistula is not sufficient for inner surface closure. 1982. J. 3. A. Monner. 86: 795. Flynn. Maw. Reconstr. Laryngoscope 91: 677. Pharyngocutaneous fistulas: Management with one-stage flap reconstruction. L. 2. Plast. 112: 423. 106: 1573. S.. Obstet. R. Nakamura. Ankara. 45 Sok. 41: 238. 1998. G. 8. 21. The sternocleidomastoid flap: Its indications and limitations.. and Liston. Surg. M.. pliable tissue with a perfect color match. Surg. L. 4. J. S. E. Surg.. Head Neck Surg. 23. 1982. However. Fabrizio. Plast. the reconstruction is performed in two stages. M. H. allowing him or her to lead a relatively normal life. 115. and Gstoettner. K.. 91: 98. H. 22. and La Velle.5. H. 1994. A... D. R. 49: 85. W. 24. Y. L. simple. and the patient’s recovery time is reduced. S. Zühtü Demir. Orthop. 1983. T. Otol. Repair of the pharyngocutaneous fistula with a fasciocutaneous island flap pedicled on the superficial temporalis artery. Zelenka... and Rasmussen. and Suen. Head Neck 22: 572. . Surg. 16. Fuji. Plast. Bresson. F. 1998. 103: 801. Pharyngocutaneous fistula after total laryngectomy: Incidence. J.. M. Harada. The submental artery flap: An anatomic study. 97: 56. 1972. E. The extended submental island lip flap: An alternative for esophageal repair. J.. 92: 867. Surg. Kuratsu. Esophagocutaneous fistula after anterior cervical spine surgery and successful treatment using a sternocleidomastoid muscle flap: A case report. P. 17. and Thimsen. Serra. 1979.. A. W. a flap prefabrication technique may be applied. Hair-bearing submental artery island ˘ flap for reconstruction of mustache and beard. 88: 835. Terzakis. 14. The etiology of postlaryngectomy pharyngo-cutaneous fistula. M. The submental island flap in head and neck reconstruction. Tojima. blood loss is less.. cause. 9. the prefabricated flap is transferred to the recipient site. and treatment. V.Vol. Arch. J. Plast. Doundoulakis. 7. Ann. R. and Bardsley. et al. J. J. K. Faltaous. and Acland. Complications of combined radiation therapy and surgery for carcinoma of the larynx and inferior hypopharynx.. The technique gives satisfactory results to both donor and recipient sites and provides a reasonable expectation for the patient of having an appearance that is acceptable cosmetically. Papazoglu. Parnes. 15. Plast. and Maw... pharynx. J. H. Br. Martin. P. Laryngol.com REFERENCES 1.. Closure of pharyngocutaneous fistulae with the rhomboid flap. Free intestinal autografts for reconstruction following pharyngolaryngoesophagectomy. S. Ü. 1986. 1991. F. Benito. Demir.. and Barutçu. J. 1994. Surg. Martin.. O. Ann. Ann. 4: 360. Pistre. The role of the free jejunal graft in reconstruction of the pharynx and cervical esophagus.. P. The submental skin has the same characteristics as neck tissue.. Y.. 2003. Baudet. G. S. Reconstr. Reconstr. and Koike. J. Combined pectoralis major myocutaneous flap with medially based deltopectoral flap for closure of large pharyngocutaneous fistulas. M. N. R. N. Lim. G. 1996. 1972. Reconstr. Otol. J.. Submental artery island flap for reconstruction of the lower and mid face.. 2001. Y. and Goldstein. 16/4 (Aytekinler Apt) 06700 Oran. A. Acta Otolaryngol. Ten years of experience with the submental flap. S. La Velle. and Doki˘ anakis. 2000. G. 11. J. D. Plast. 10. 6: 762. In the first (prefabrication) stage. Dikmen Mah. A. Pharyngoesophageal structure and fistula: Treatment by free jejunal graft. M. Clin. Sterne. Surg.. Robb. D. Reconstr. J... a submental island flap is elevated and an epithelial lining is created by placement of a non– hair-bearing skin graft on the inner surface of the flap. Surg. 267: 8. consisting of thin.. Vural. 12. et al.. 51: 175.. Yilmaz. T. The submental island flap: A new donor site. C. Menderes.. I.. O. Nahai. D. Donati. F.. J. The management of postoperative pharyngocutaneous pharyngeal fistulae. 5. we have no experience with the prefabricated submental island flap for pharyngocutaneous fistula closure. A.. A. No. 1993. Plast.. Pelissier. M.. Gynecol. 108: 1576. Anatomy and clinical 6. et al. and Yetman.. Surg. and the maximum submental island flap size was 6 3 cm in our series. Head Neck Surg. T. G.. T. Surg. Turkey zuhtudemir@hotmail. J.. as documented by injection studies. Reconstr. 16: 125. 1997. Ann. Pharyngocutaneous fistulae in totally laryngectomized patients. and Baudet. and ¸ ˘ Çelebioglu. Pascal. J. Janssen. Kierner.. Ann. Shirasaki. F. Maisel.38 However. Ann. et al. R. Gluckman. safe. Reconstruction of pharyngostomas with a modified deltopectoral flap combining endoscopy and tissue expansion. Velidedeoglu. and Nava. A. Surg. Kimura. R. Z. The submental island flap.. Januszkiewicz. and reliable technique. The skin territory of the submental island flap can be as large as 10 16 cm. Laryngoscope 95: 224. Plast. and Dunegan. Laryngol. C. Ürdün Cad. This study has demonstrated that pharyngocutaneous fistula repair with the submental artery island flap is a single-stage. R.. C. Thawley. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 43 applications as a free or pedicled flap.D.. McDonough. A. A. 18. and Swartz. Laryngoscope 111: 2201. J.. McConnel.. 1996. After complete graft take is accomplished. and this can be the subject of another clinical study. It has a shorter operation time. Deltopectoral flap for one-stage reconstruction of pharyngocutaneous fistulae following total laryngectomy. A. R. Hall. A. 1981. D. 95: 10. Hester. Surg. Rasmussen. 2000. Plast. Otol. 1974. 149: 858. V. 39: 30.. Rhinol. Sahin. 13. 2001. Plast. Otolaryngol. J. Kurtay.. R. Y. 19. 102: 835.
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