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Repair of Pharyngocutaneous Fistulas with the

Submental Artery Island Flap


Zühtü Demir, M.D., Hifzi Velidedeoğlu, M.D., and Selim Çelebioğlu, M.D.
Ankara, Turkey

After surgery for conditions such as laryngeal


Pharyngocutaneous fistulas after total laryn- cancer or hypopharyngeal cancer, salivary pha-
gectomy are difficult to manage and are a cause ryngocutaneous fistulas are sometimes trouble-
for significant morbidity to the patient. When some complications. In the literature, the fre-
fistulas fail to close with conservative measures, quency of fistula formation varies from 2 to 66
débridement and flap closure are indicated. percent.1–3 Patients suffer considerable pro-
Although a number of techniques to repair longed morbidity including salivary leakage, pro-
pharyngocutaneous fistulas are described, each tracted difficulties in deglutition, and delay in
of these procedures has its drawbacks. The au- postoperative irradiation when indicated. In gen-
thors have used the submental island flap to eral, these problems occur in patients who are
close postoperative pharyngocutaneous fistulas compromised by malnutrition, advanced disease,
in nine male patients during the past 4 years. ischemic tissues secondary to irradiation, and in-
The mean patient age was 65 years (range, 57 fection. The management of these fistulas is a
to 75 years). The submental island flap is based challenge for the surgeon and patient. Although
on the submental artery, a branch of the facial most fistulas are small and heal spontaneously,
artery. The inner aspect of the fistula was ini- larger fistulas require surgical reconstruction.
tially formed using hinge flaps on the skin The surgical reconstruction requires imagination
around the fistula. Once a watertight closure and technical skill. A number of methods to close
of inner side was created, the skin defect such pharyngocutaneous fistulas are available.
was closed with the submental island flap. Myocutaneous and free flaps have become the
The maximum flap size was 6 ⫻ 3 cm and the standard of care for these fistulas. However, each
minimum size was 4 ⫻ 2 cm (average, 4.8 ⫻ of these techniques has its drawbacks.4
2.7 cm) in this series. Direct closure was The submental island flap, an axial pattern
achieved at all donor sites. Patients were flap first introduced by Martin et al. in 1993,5 is
followed for 6 months to 4 years. No major a reliable source of skin in the reconstruction
complication was noted in the postopera- of various head and neck defects. We have used
tive period. All patients have successfully this flap for closing pharyngocutaneous fistulas
recovered their swallowing function. The that have been created at or developed after
submental island flap is safe, rapid, and surgery. In this report, we present our clinical
simple to elevate and leaves minimal donor- experience with use of the submental artery
site morbidity. The authors believe that this island flap for the reconstruction of pharyngo-
technique is a good alternative in the cutaneous fistulas.
reconstruction of pharyngocutaneous fis-
tulas. Application of the technique and PATIENTS AND METHODS
results are discussed. (Plast. Reconstr.
Surg. 115: 38, 2005.) 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
38
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 39
laryngeal cancer that required radiotherapy af- the origin of the facial vessels to achieve a long
ter laryngectomy. The mean age was 65 years pedicle. In this way, the submental artery island
(range, 57 to 75 years) (Table I). The patients flap is created. The flap is then tunneled to the
underwent total laryngectomy and developed a recipient site to the second layer closure. The
salivary pharyngocutaneous fistula after opera- donor site closes directly without additional
tion. Pressure dressing and primary repair dissection.
were attempted in all of the patients, though Three weeks postoperatively, a dilute barium
without success. radiograph was obtained, the nasoesophageal
feeding tube was removed, and the patient was
Technique started on a clear liquid diet. After 4 weeks,
Six patients were operated on under local they were placed on a mechanical soft diet.
anesthesia with sedation. The others were op-
erated on under general anesthesia. The pa- RESULTS
tient is placed in supine position with the head The patients were observed for 6 months to
and neck moderately extended. First, an ellip- 4 years. During this period, no major compli-
tical flap around the fistula is designed to re- cation was noted and satisfactory results were
pair the inner surface of the pharynx. A skin obtained. The maximum flap size was 6 ⫻ 3 cm
incision is made around the flap and the tissue and the minimum size was 4 ⫻ 2 cm (average,
is undermined up to the point of the fistula. 4.8 ⫻ 2.7 cm) (Table I). All donor defects were
The undermined skin edges of the ellipse are closed primarily. There were no problems with
then inverted in a trapdoor fashion, and su- the marginal mandibular branch of the facial
tures are placed in the subcutaneous fat to nerve. Venous congestion was observed on the
create an inner squamous cell lining. This clo- second postoperative day in only one flap and
sure can be tested by having the patient swal- subsided spontaneously. All flaps survived com-
low either methylene blue or grape juice. Once pletely. Dilute barium radiography performed
a watertight closure is achieved, the submental 3 weeks after the operation showed normal
island flap is planned according to the cutane- continuity of the upper digestive tract in all
ous defect size. The detailed anatomy of the patients. Two case reports are presented.
submental island flap is presented else-
where.5–11 The upper limit of the flap is marked CASE REPORTS
just under the mandibular arc to avoid a visible
scar. After incising the borders of the flap, the Case 1
dissection is carried down through the A 73-year-old man had previously undergone laryngec-
platysma muscle, with careful preservation of tomy. A complication of his laryngectomy was a pharyngo-
cutaneous fistula (Fig. 1). There was no evidence of recurrent
the marginal mandibular nerves. The flap is tumor. The operation was performed under light sedation
then elevated in an inferior fashion in the sub- and local anesthesia. After the inner side watertight closure
platysmal plane. The submental vessels are was performed using the local tissue around the fistula, a 2.5
identified near the inferior border of the man- ⫻ 4.5-cm cutaneous defect was created. A 3⫻5-cm submental
dible on the flap pedicle side. The flap is then island flap was planned and elevated on the right side sub-
mental vessels (Fig. 1, above, right). The flap was then passed
mobilized from the mandible, and the sub- to the defect through a subcutaneous tunnel for the second
mental vessels can now be dissected back to the layer closure. (Fig. 1, below). The donor site was closed pri-
facial vessels. Dissection can be carried down to marily. The postoperative course was uncomplicated. The

TABLE I
Patient and Flap Data

Age Flap Size Postoperative Stay Oral Intake Follow-Up


Patient (yr) Primary Lesion (cm) Complications (days) Days Duration (yr)

1 61 Larynx 5⫻3 None 1 22 4


2 57 Larynx 4⫻3 None 2 21 4
3 73 Larynx 5⫻3 None 1 23 3
4 62 Larynx 6⫻3 None 1 22 3
5 68 Larynx 4.5 ⫻ 3 None 1 24 3
6 72 Larynx 6⫻3 None 3 23 2
7 58 Larynx 4⫻2 None 1 22 1
8 75 Larynx 5⫻2 None 2 21 1
9 59 Larynx 4⫻3 None 1 24 1/2
40 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005

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.

of a pharyngocutaneous fistula in a patient. branch of the facial artery. It supplies an ex-


They used a skin graft for donor-site closure. tensive area of the ipsilateral upper neck and a
Other described techniques have to be con- variable area across the midline. Because of
sidered along with the use of free flaps. Free rich subcutaneous and subdermal anastomoses
intestinal flaps provide the ability to close between the two submental arteries, the sub-
larger fistulas in a one-stage operation.22–24 mental artery island flap can be easily raised on
However, these procedures can be quite exten- one side pedicle successfully and rotated to the
sive and can involve considerable risk.17 whole homolateral face and neck. The surgical
The free radial forearm flap is a suitable advantage of an axial flap, which has a recog-
alternative for the reconstruction of pharyngo- nizable arterial and venous circulation that the
cutaneous fistulas.25–28 Because it requires har- long axis of the flap can follow and which
vesting from a second operative site, which is yields branches to the dermal-subdermal
time consuming, it may leave a troublesome plexus, is clear. The blood supply of the skin of
scar and has its inherent complications. Mor- the head and neck in general is known to be
bidity of the donor site is another factor for rich, and the vascularity of this flap specifically
consideration.29 –31 Another major problem is so good that we have no hesitation using the
with this technique is that it necessitates sacri- flap closure for pharyngocutaneous fistulas in
fice of a major artery to the hand. Although heavily irradiated tissue.
problems following division of the radial artery The major drawback of this technique is a
are rare, some cases have been reported.32 It is previous bilateral neck dissection where both
also very risky to use microsurgical techniques of the facial arteries may have been killed.
because of functional and structural alteration However, in patients who have undergone pre-
of the local vascular pedicles after radiotherapy vious ipsilateral neck dissections, the submen-
for adjuvant treatment of head and neck tal artery island flap can be raised on the con-
cancer.12,17,33–37 tralateral side pedicle successfully and inset
The submental artery island flap is very ver- into the defect. In our five patients with previ-
satile and durable for closure of facial de- ous ipsilateral neck dissection, we used the sub-
fects.5–10 Using the principles originally de- mental island flap based on the contralateral
scribed by Martin et al.,5 we have repaired site without any problem.
pharyngocutaneous fistulas with the submental An elliptical flap designed around the fistula
island flap. The submental artery is a consistent was sufficient to repair the inner surface of the
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 43
pharynx, and the maximum submental island applications as a free or pedicled flap. Plast. Reconstr.
flap size was 6 ⫻ 3 cm in our series. The skin Surg. 92: 867, 1993.
6. Demir, Z., Kurtay, A. Şahin, Ü., Velidedeoğlu, H., and
territory of the submental island flap can be as Çelebioğlu, S. Hair-bearing submental artery island
large as 10 ⫻ 16 cm, as documented by injec- flap for reconstruction of mustache and beard. Plast.
tion studies.5,11 In patients with larger fistulas in Reconstr. Surg. 112: 423, 2003.
which the skin around the fistula is not suffi- 7. Yilmaz, M., Menderes, A., and Barutçu, A. Submental
cient for inner surface closure, a flap prefabri- artery island flap for reconstruction of the lower and
mid face. Ann. Plast. Surg. 39: 30, 1997.
cation technique may be applied.38 However,
8. Pistre, V., Pelissier, P., Martin, D., Lim, A., and Baudet,
the reconstruction is performed in two stages. J. Ten years of experience with the submental flap.
In the first (prefabrication) stage, a submental Plast. Reconstr. Surg. 108: 1576, 2001.
island flap is elevated and an epithelial lining is 9. Vural, E., and Suen, J. Y. The submental island flap in
created by placement of a non– hair-bearing head and neck reconstruction. Head Neck 22: 572,
skin graft on the inner surface of the flap. After 2000.
10. Sterne, G. D., Januszkiewicz, J. S., Hall, P. N., and Bard-
complete graft take is accomplished, the pre- sley, A. F. The submental island flap. Br. J. Plast. Surg.
fabricated flap is transferred to the recipient 49: 85, 1996.
site. However, we have no experience with the 11. Faltaous, A. A., and Yetman, R. J. The submental artery
prefabricated submental island flap for pharyn- flap: An anatomic study. Plast. Reconstr. Surg. 97: 56,
gocutaneous fistula closure, and this can be the 1996.
12. Fabrizio, T., Donati, V., and Nava, M. Repair of the
subject of another clinical study.
pharyngocutaneous fistula with a fasciocutaneous is-
This study has demonstrated that pharyngo- land flap pedicled on the superficial temporalis artery.
cutaneous fistula repair with the submental ar- Plast. Reconstr. Surg. 106: 1573, 2000.
tery island flap is a single-stage, safe, simple, 13. La Velle, R. J., and Maw, A. R. The etiology of postlar-
and reliable technique. It has a shorter opera- yngectomy pharyngo-cutaneous fistula. Arch. Otolaryn-
tion time, blood loss is less, and the patient’s gol. Head Neck Surg. 95: 10, 1972.
14. Bresson, K., Rasmussen, H., and Rasmussen, P. A. Pha-
recovery time is reduced. The submental skin ryngocutaneous fistulae in totally laryngectomized pa-
has the same characteristics as neck tissue, con- tients. J. Laryngol. Otol. 88: 835, 1974.
sisting of thin, pliable tissue with a perfect 15. Maw, A. R., and La Velle, R. J. The management of
color match. The technique gives satisfactory postoperative pharyngocutaneous pharyngeal fistu-
results to both donor and recipient sites and lae. J. Laryngol. Otol. 86: 795, 1972.
provides a reasonable expectation for the pa- 16. Parnes, S. M., and Goldstein, J. C. Closure of pharyn-
gocutaneous fistulae with the rhomboid flap. Laryn-
tient of having an appearance that is accept- goscope 95: 224, 1985.
able cosmetically, allowing him or her to lead a 17. Janssen, D. A., and Thimsen, D. A. The extended sub-
relatively normal life. mental island lip flap: An alternative for esophageal
repair. Plast. Reconstr. Surg. 102: 835, 1998.
Zühtü Demir, M.D. 18. Serra, J. M., Benito, J. R., Monner, J., et al. Reconstruc-
tion of pharyngostomas with a modified deltopectoral
Y. Dikmen Mah. Ürdün Cad. 45 flap combining endoscopy and tissue expansion. Ann.
Sok. 16/4 (Aytekinler Apt) Plast. Surg. 41: 238, 1998.
06700 Oran, Ankara, Turkey 19. Kierner, A. C., Zelenka, I., and Gstoettner, W. The ster-
zuhtudemir@hotmail.com nocleidomastoid flap: Its indications and limitations.
Laryngoscope 111: 2201, 2001.
20. Fuji, T., Kuratsu, S., Shirasaki, N., et al. Esophagocuta-
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