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Delayed platysma myocutaneous turnover flap forrepair of pharyngocutaneous fistula☆

Paul Neubauer, MDa,⁎, Karina Cañadas, MDb, Clarence T. Sasaki, MDa

a Section of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, CT, USAb Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA

A R T I C L E I N F O

☆ No source of funding. No financial disclos⁎ Corresponding author at: Section of Otolary

E-mail address: paul.neubauer@yale.edu

http://dx.doi.org/10.1016/j.amjoto.2014.08.0150196-0709/© 2014 Elsevier Inc. All rights rese

Please cite this article as: Neubauer P, etfistula, Am J Otolaryngol–Head and Neck

A B S T R A C T

Article history:Received 30 July 2014

Introduction: Pharyngocutaneous fistula (PCF) is a common and serious complication aftertotal laryngectomy. Numerous surgical and non-surgical treatment approaches have beendescribed. Here we describe a platysma myocutaneous turnover flap for repair of PCF.Materials and methods: Platysma myocutaneous turnover flap is described and twopatients are used as examples.Results: Repair was initially successful in both patients; however, one patient hadrecurrence of fistula after her cancer recurred at the stoma.Discussion: Numerous surgical techniques have been described for repair of PCF. Here aturnover flap was used, a technique not previously described for this problem. The delaytechnique enhances the viability of the flap thought to be through numerous mechanisms.Conclusion: The platysma myocutaneous turnover flap is useful for closure ofpharyngocutaneous fistula when non-operative measures have failed.

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

Pharyngocutaneous fistula (PCF) is awell-known complication oflaryngectomy, occurring in 9%–35% of patients who have hadprevious radiation therapy for their laryngeal cancer [1]. Devel-opment of a PCF is further associated with several negativesequelae, including delayed oral feeding, longer hospital stays,and unfavorable social ramifications. Risk factors for thedevelopment of PCF are numerous and include previousradiation therapy, short interval between previous radiationtherapy and surgery [2], advanced primary T and N stage, non-glottic primary site, resection of hyoid bone, high total radiationdose, large radiation field [1,3], intraoperative blood transfusions[4], presenceof residual tumor [5], and concomitantneckbilateralneck dissection [3], among many others.

There are both non-surgical and surgical options fortreatment of PCF but there is no consensus for the best

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treatment. Non-surgical treatment options include prolongednil per os (NPO) status, acetic acid rinses, antibiotics andsalivary bypass tubes. Surgical options include direct closure,local and regional flaps, and free flaps. The treatment choicedepends on the size and location of the fistula, taking intoaccount the patient's health status, radiation history, and necktissue [6]. We advocate a delayed platysma myocutaneousturnover flap for the repair of PCF, a technique we believe hasnot been previously described.

2. Materials and methods

In our practice we have a high volume of patients who havefailed chemoradiation for their laryngeal cancer. Often theyrequire a salvage total laryngectomy for which we prophylac-tically add a pectoralis major flap (PMF), given impaired

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yocutaneous turnover flap for repair of pharyngocutaneousttp://dx.doi.org/10.1016/j.amjoto.2014.08.015

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wound healing resulting from radiation which can lead tofistulas. When a PCF occurs despite the PMF, we advocate fora delayed outline platysma myocutaneous turnover flap withgood results. We illustrate two such cases using thistechnique that led to complete closure of the PCF andsuccessful resumption of oral feeds in both cases.

Fig. 1 – (A) Outline of flap shown raised and sewn back in place(B), which is performed in the stage one of the procedure.

3. Patient selection

D.A. is a 78 year-old male who was referred to our practice forT2N0 left aryepiglottic fold squamous cell carcinoma. He wasinitially treated with laser supraglottic laryngectomy followedby radiation but unfortunately tumor recurred. He underwenta salvage total laryngectomy and PMF but soon developed aPCF. The defect was initially treated conservatively withDakins packing to the fistula site, a salivary bypass tube andNPO status. The patient was non-compliant with his NPOstatus and had several other co-morbidities, such as diabetes,hypertension and psychiatric disorders. After several months,the defect persisted and measured 2 × 2 cm. A decision wasthen made to bring patient to operating room for delayedplatysma myocutaneous turnover flap.

Similarly, P.B is a 77 year-old female with a history of T2N1left true vocal cord cancer treated initially with radiation whichfailed to control disease. She was then treated with salvage totallaryngectomywith PMF butwent on to develop a PCF, likely frompoor wound healing from radiation and prolonged steroids,whichshehadbeen taking for asthma. LikeD.A, a salivary bypasstube was placed and she was made NPO with Dakins packing tothe fistula site. Despite this, a 1.5 × 1.5 cm fistula persisted andshe was ultimately taken to the operating room for a delayedplatysmamyocutaneous turnover flap.

4. Technique

Both patients were treated in similar fashions as outlined below.Using a 15-blade, a U-shaped outline delay was incised

superior to the fistula with the intention of using this as aturnover flap in 10–14 days in an attempt to definitively closethe fistula. The outlined flap was then re-sutured in itsnormal anatomic position using three 5–0 nylon sutures in aninterrupted fashion (Fig. 1).

Two weeks later, the patient returned for the second andfinal part of the procedure. The sutures of the previouslyoutlined flap were removed and the outline delay wasreleased and undermined toward the fistula. The circumfer-ence of the turnover flap was denuded of epitheliumapproximately 3 mm from the edge of the flap itself. Acircumferential incision was made surrounding the fistulaand the epithelium was dissected out toward the edge of thefistula in order to allow the epithelium to be reflected into thepharynx (Fig. 2A). The skin surrounding the fistula was alsodenuded 360 degrees to create sufficient imbrication forremnants of the originally placed PMF to later be placed in alayered fashion over the turnover flap. The fistula itself wasthen closed with interrupted 5-0 Maxon sutures for a water-tight seal. The wound was then irrigated and the remnants of

Please cite this article as: Neubauer P, et al, Delayed platysma mfistula, Am J Otolaryngol–Head and Neck Med and Surg (2014), h

the PMF were then elevated. (In the case of DA, a second PMFwas done due to lack of useable tissue from the originallyplaced PMF). The PMFmuscle flap was then advanced over theturnover flap. The surrounding skin was undermined and theremaining defect was closed to make a new laryngectomystoma (Fig. 2B).

5. Results

Both patients achieved resolution of their fistulae after theirdelayed outline platysma myocutaneous turnover flap. D.A.achieved a durable resolution of his fistula. Two months afterP.B.'s turnover flap, she presented to the clinic with drainagefrom her stoma at the one o'clock position. An area ofinflammatory tissue was noted at the site, which wasbiopsied and found to be recurrent squamous cell carcinoma.

6. Discussion

PCF is a challenging problem following laryngectomy. Nu-merous methods have been described to close PCFs, includingdirect closure, myocutaneous, fasciocutaneous and muscle

yocutaneous turnover flap for repair of pharyngocutaneousttp://dx.doi.org/10.1016/j.amjoto.2014.08.015

Fig. 2 – (A) The outline delay flapwas released andunderminedtoward the fistula. It was then flipped inferiorly to cover the PCFafter the surrounding skin had been denuded. (B) The originallyplaced PMFwas then lifted and layered over the turnover flap toreinforce it. The neck incision was then extended laterally andundermined. The defect was then closed, sutured and aPenrose drain was placed.

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local and regional flaps, including sternocleidomastoid,pectoralis major, and latissiumus muscle flaps [6]. Free flapshave also been described, including, radial forearm free flaps[7], gastro-omental flaps [8], and jejunal flaps [9].

Surgical closure of PCF is likely needed in previouslyirradiated patients [6,10–12]. Direct closure is useful only forsmall defects. Free tissue transfer is complicated by the lackof available neck vessels and long surgical time which canlimit the applicability in older and medical fragile patients. Adelayed turnover flap is simpler, presumably better toleratedand less morbid than regional or free flaps because itmaximizes the use of the surrounding tissue.

Turnover flaps have been described in the lower extrem-ities to close wounds. They are suitable for small defects andhave had success with patients with poor lower extremityblood supply with end-stage vascular disease [13]. Epithelialturnover flaps are described in the head and neck to close atracheocutaneous fistula [14].

The delay technique is a well-established phenomenon toimprove the blood supply and increase survival to a flap [15].

Please cite this article as: Neubauer P, et al, Delayed platysma mfistula, Am J Otolaryngol–Head and Neck Med and Surg (2014), h

Delay procedures involve raising a skin flap with a singlepedicle, partially devascularizing tissue for a period of timebefore transposing the tissue. Its mechanism, althoughextensively studied, is still unclear. The improved survival isthought to be due to creation of ischemia by conditioning cellsto the ischemic environment [16]. Additionally, the closure ofarterio-venous shunts after raising the flap may contribute[17]. Dilation and reorientation of blood vessels in the flapfrom the sympathectomy created from raising the flap isthought to play a part as well [18]. Lastly, angiogenesis mayoccur as well due to the relative ischemia [18,19]. We believethat the delay turnover flap technique enhances the flap'sblood supply from the vessels in the superficial cervicalfascia. The coverage of the flap is maximized because, afterthe delay, the tissue will not likely contract significantly.

7. Conclusion

The delayed turnover myocutaneous flap described here isuseful for closure of PCF where non-operative measures havefailed. The delay phenomenon helps compensate for thedeleterious effects of radiation on the tissue in salvage totallaryngectomy, as seen in our patients. The adjacentmyocutaneous flap is less morbid than a regional muscleflap, despite being a two-stage procedure, and more effectivethan direct closure or a local skin flap, and less morbid thana free-flap.

R E F E R E N C E S

[1] Grau C, Johansen LV, Hansen HS, et al. Salvage laryngectomyand pharyngocutaneous fistulae after primary radiotherapyfor head and neck cancer: a national survey from DAHANCA.Head Neck 2003;25:711–6.

[2] Virtaniemi JA, Kumpulainen EJ, Hirvikoski PP, Johansson RT,Kosma VM. The incidence and etiology of postlaryngectomypharyngocutaneous fistulae. Head Neck 2001;23:29–33.

[3] Basheeth N, O'leary G, Sheahan P. Pharyngocutaneous fistulaafter salvage laryngectomy: impact of interval betweenradiotherapy and surgery, and performance of bilateral neckdissection. Head Neck 2014;36:580–4.

[4] Hier M, Black MJ, Lafond G. Pharyngo-cutaneous fistulas aftertotal laryngectomy: incidence, etiology and outcomeanalysis. J Otolaryngol 1993;22:164–6.

[5] Lundgren J, Olofsson J. Pharyngocutaneous fistulae followingtotal laryngectomy. Clin Otolaryngol Allied Sci 1979;4:13–23.

[6] Mclean JN, Nicholas C, Duggal P, et al. Surgical managementof pharyngocutaneous fistula after total laryngectomy. AnnPlast Surg 2012;68:442–5.

[7] Magdy EA. Surgical closure of postlaryngectomypharyngocutaneous fistula: a defect based approach. EurArch Otorhinolaryngol 2008;265:97–104.

[8] Carlson GW, Thourani VH, Codner MA, Grist WJ. Freegastro-omental flap reconstruction of the complex,irradiated pharyngeal wound. Head Neck 1997;19:68–71.

[9] De vries EJ, Myers EN, Johnson JT, et al. Jejunal interpositionfor repair of stricture or fistula after laryngectomy. Ann OtolRhinol Laryngol 1990;99:496–8.

[10] Bresson K, Rasmussen H, Rasmussen PA. Pharyngo-cutaneous fistulae in totally laryngectomized patients.J Laryngol Otol 1974;88:835–42.

yocutaneous turnover flap for repair of pharyngocutaneousttp://dx.doi.org/10.1016/j.amjoto.2014.08.015

4 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y – H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y X X ( 2 0 1 4 ) X X X – X X X

[11] Ikiz AO, Uça M, Güneri EA, Erdağ TK, Sütay S.Pharyngocutaneous fistula and total laryngectomy: possiblepredisposing factors, with emphasis on pharyngealmyotomy. J Laryngol Otol 2000;114:768–71.

[12] Papazoglou G, Doundoulakis G, Terzakis G, Dokianakis G.Pharyngocutaneous fistula after total laryngectomy:incidence, cause, and treatment. Ann Otol Rhinol Laryngol1994;103:801–5.

[13] Mitra A, Spears J, Newsome E, Mccampbell B, Kiran R, Mitra A.Expanding the scope of the turnover flap. Plast Reconstr Surg2006;118:125–33.

[14] Kamiyoshihara M, Nagashima T, Takeyoshi I. A noveltechnique for closing a tracheocutaneous fistula using ahinged skin flap. Surg Today 2011;41:1166–8.

Please cite this article as: Neubauer P, et al, Delayed platysma mfistula, Am J Otolaryngol–Head and Neck Med and Surg (2014), h

[15] Taylor GI, Corlett RJ, Caddy CM, Zelt RG. An anatomic reviewof the delay phenomenon: II. Clinical applications. PlastReconstr Surg 1992;89:408–16.

[16] McFarlane RM, Heagy FC, Radin S, Aust JC, Wermuth RE. Astudy of the delay phenomenon in experimental pedicleflaps. Plast Reconstr Surg 1965;35:245–62.

[17] Reinisch JF. The pathophysiology of skin flap circulation. Thedelay phenomenon. Plast Reconstr Surg 1974;54:585–98.

[18] Ghali S, Butler PE, Tepper OM, Gurtner GC. Vascular delayrevisited. Plast Reconstr Surg 2007;119:1735–44.

[19] Holzbach T, Neshkova I, Vlaskou D, et al. Searching for theright timing of surgical delay: angiogenesis, vascularendothelial growth factor and perfusion changes in a skin-flap model. J Plast Reconstr Aesthet Surg 2009;62:1534–42.

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