TABLE I
Patient and Flap Data
FIG. 1. (Above, left) The first patient with pharyngocutaneous fistula before the oper-
ation. (Above, right) Skin markings for the elliptical flap around the fistula and submental
artery island flap based 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.
patient was discharged from the hospital with continued tube complication was observed in the postoperative period. The
feeding on the first postoperative day. Three weeks postop- patient was discharged on the first postoperative day with a
eratively, a dilute barium radiograph showed a patent upper nasoesophageal feeding tube. A clear diet was given orally 3
digestive tract, and the patient was started on a clear diet (Fig. weeks after the operation and no fistula and stenosis was
2). A mechanical soft diet was started in the fourth postop- revealed by dilute barium radiography (Fig. 4, center). Four
erative week without evidence of fistula or stenosis (Fig. 3). weeks postoperatively, a mechanical soft diet was started (Fig.
4, right).
Case 2
A 68-year-old man suffered from a pharyngocutaneous DISCUSSION
fistula that occurred immediately after total laryngectomy at
another center. When we first examined the patient, the Postoperative pharyngocutaneous fistula is a
fistula measured 0.9 ⫻ 2.3 cm (Fig. 4, left). We decided to use relatively frequent complication of total laryn-
a submental island flap for fistula repair. The operative pro- gectomy that prolongs the hospitalization of 2
cedure was similar to that used in case 1. After closure of the to 3 weeks to many weeks or even months.1 The
inner surface of the pharynx, a 2.5 ⫻ 4-cm cutaneous defect
was created and a 3 ⫻ 4.5-cm submandibular island flap was cause of pharyngocutaneous fistula formation
raised on the right side submental artery. The flap was passed may be linked directly to local tissue ischemia
through a subcutaneous tunnel for second-layer closure. No followed by infection and subsequent wound
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 41
Small or medium-size fistulas, especially in
nonirradiated patients, usually close spontane-
ously with conservative therapy. Early conserva-
tive fistula management consists of adequate
wound drainage, pressure dressing, frequent
use of suction catheters, antiseptic gauze pack-
ing, minimal débridement, nasogastric feed-
ings, and frequent antibiotic oral swishes to
irrigate the fistula.1,2,15 Spontaneous closure is
expected in approximately two-thirds of these
patients, especially those who have a small an-
terior or laterally positioned fistula where the
greater portion of the neck wound is healed.1,2
When fistulas fail to close with conservative
measures, débridement and flap closure are
indicated. Surgical treatment is not yet stan-
dardized and, at present, it is impossible to
envisage an ideal solution for repairing com-
plex lesions. The reconstruction requires imag-
ination and technical skill. Direct closure is not
adequate for larger wounds, especially in radi-
FIG. 2. Radiograph of the normal continuity of the upper ation fields.
digestive tract 3 weeks after the operation. Local procedures such as rhomboid flaps,
rotation and transposition flaps, and lateral
cervical flaps have been used.2,4,12,16 However,
because of the random pattern vascular supply
of these flaps, the failure rate has remained
high and the risk of tissue necrosis after neck
dissection and heavy radiation discourages
their use.1,2,4,12,17
The Bakamjian flap, elevated from the del-
topectoral region based on an axial vascular-
ization coming from cutaneous branches of
the intercostal arteries, has long been the flap
of choice for closure of large pharyngocutane-
ous fistulas. However, it usually requires two
reconstructive procedures and leaves major
aesthetic sequelae.2,4,12,18
Sternocleidomastoid muscle flaps have been
used for closure of nonmalignant fistulas.17,19,20
The pectoralis major flap can be used with or
without a skin island. However, it is very bulky
and is generally indicated in cases of large
substance loss in the pharyngolaryngeal
area.2,12,21
FIG. 3. Final results of the first patient.
Janssen and Thimsen reported the use of a
breakdown. Contributing factors include ad- full-thickness flap involving the middle third of
vanced disease and poor nutritional status, as the lower lip based on the submental artery for
evidenced by decreased serum protein and he- full-thickness closure of cervical esophagocuta-
moglobin levels. Radiotherapy together with neous fistulas.17 However, the important draw-
wound infection is one of the main causes of back to this procedure is the aesthetic change
this pathologic condition. A relationship be- in the central third of the lower lip.
tween fistula formation and neck dissection, Fabrizio et al.12 reported the use of the fas-
coexisting systemic disease, and size and site of ciocutaneous island flap pedicled on the super-
tumor has also been found.1,2,4,12–14 ficial temporalis artery for the reconstruction
42 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
FIG. 4. (Left) Appearance of the patient in case 2, who suffered from pharyngocutaneous fistula. (Center) Radiograph obtained
3 weeks postoperatively showing the patent upper digestive tract of patient 2. (Right) Postoperative appearance, 6 months after
the operation.