Repair of Pharyngocutaneous Fistulas with theSubmental Artery Island FlapZühtü Demir, M.D., Hifzi Velidedeoglu, M.D., and Selim Çelebioglu, M.D.Ankara, Turkey

Pharyngocutaneous fistulas after total laryn-gectomy are difficult to manage and are a causefor significant morbidity to the patient. Whenfistulas fail to close with conservative measures,débridement and flap closure are indicated.Although a number of techniques to repairpharyngocutaneous fistulas are described, eachof these procedures has its drawbacks. The au-thors have used the submental island flap toclose postoperative pharyngocutaneous fistulasin nine male patients during the past 4 years.The mean patient age was 65 years (range, 57to 75 years). The submental island flap is basedon the submental artery, a branch of the facialartery. The inner aspect of the fistula was ini-tially formed using hinge flaps on the skinaround the fistula. Once a watertight closureof inner side was created, the skin defectwas closed with the submental island flap.The maximum flap size was 6 � 3 cm and theminimum size was 4 � 2 cm (average, 4.8 �2.7 cm) in this series. Direct closure wasachieved at all donor sites. Patients werefollowed for 6 months to 4 years. No majorcomplication was noted in the postopera-tive period. All patients have successfullyrecovered their swallowing function. Thesubmental island flap is safe, rapid, andsimple to elevate and leaves minimal donor-site morbidity. The authors believe that thistechnique is a good alternative in thereconstruction of pharyngocutaneous fis-tulas. Application of the technique andresults are discussed. (Plast. Reconstr.Surg. 115: 38, 2005.)

After surgery for conditions such as laryngealcancer or hypopharyngeal cancer, salivary pha-ryngocutaneous fistulas are sometimes trouble-some complications. In the literature, the fre-quency of fistula formation varies from 2 to 66percent.1–3 Patients suffer considerable pro-longed morbidity including salivary leakage, pro-tracted difficulties in deglutition, and delay inpostoperative irradiation when indicated. In gen-eral, these problems occur in patients who arecompromised by malnutrition, advanced disease,ischemic tissues secondary to irradiation, and in-fection. The management of these fistulas is achallenge for the surgeon and patient. Althoughmost fistulas are small and heal spontaneously,larger fistulas require surgical reconstruction.The surgical reconstruction requires imaginationand technical skill. A number of methods to closesuch pharyngocutaneous fistulas are available.Myocutaneous and free flaps have become thestandard of care for these fistulas. However, eachof these techniques has its drawbacks.4

The submental island flap, an axial patternflap first introduced by Martin et al. in 1993,5 isa reliable source of skin in the reconstructionof various head and neck defects. We have usedthis flap for closing pharyngocutaneous fistulasthat have been created at or developed aftersurgery. In this report, we present our clinicalexperience with use of the submental arteryisland flap for the reconstruction of pharyngo-cutaneous fistulas.

PATIENTS AND METHODS

We have repaired nine pharyngocutaneousfistulas using the submental island flap in thepast 4 years. All patients were men and had

From the Department of Plastic and Reconstructive Surgery, Social Security Foundation Ankara Research Hospital. Received for publicationAugust 29, 2003; revised January 26, 2004.

DOI: 10.1097/01.PRS.0000145941.51938.67

38

laryngeal cancer that required radiotherapy af-ter laryngectomy. The mean age was 65 years(range, 57 to 75 years) (Table I). The patientsunderwent total laryngectomy and developed asalivary pharyngocutaneous fistula after opera-tion. Pressure dressing and primary repairwere attempted in all of the patients, thoughwithout success.

Technique

Six patients were operated on under localanesthesia with sedation. The others were op-erated on under general anesthesia. The pa-tient is placed in supine position with the headand neck moderately extended. First, an ellip-tical flap around the fistula is designed to re-pair the inner surface of the pharynx. A skinincision is made around the flap and the tissueis undermined up to the point of the fistula.The undermined skin edges of the ellipse arethen inverted in a trapdoor fashion, and su-tures are placed in the subcutaneous fat tocreate an inner squamous cell lining. This clo-sure can be tested by having the patient swal-low either methylene blue or grape juice. Oncea watertight closure is achieved, the submentalisland flap is planned according to the cutane-ous defect size. The detailed anatomy of thesubmental island flap is presented else-where.5–11 The upper limit of the flap is markedjust under the mandibular arc to avoid a visiblescar. After incising the borders of the flap, thedissection is carried down through theplatysma muscle, with careful preservation ofthe marginal mandibular nerves. The flap isthen elevated in an inferior fashion in the sub-platysmal plane. The submental vessels areidentified near the inferior border of the man-dible on the flap pedicle side. The flap is thenmobilized from the mandible, and the sub-mental vessels can now be dissected back to thefacial vessels. Dissection can be carried down to

the origin of the facial vessels to achieve a longpedicle. In this way, the submental artery islandflap is created. The flap is then tunneled to therecipient site to the second layer closure. Thedonor site closes directly without additionaldissection.

Three weeks postoperatively, a dilute bariumradiograph was obtained, the nasoesophagealfeeding tube was removed, and the patient wasstarted on a clear liquid diet. After 4 weeks,they were placed on a mechanical soft diet.

RESULTS

The patients were observed for 6 months to4 years. During this period, no major compli-cation was noted and satisfactory results wereobtained. The maximum flap size was 6 � 3 cmand the minimum size was 4 � 2 cm (average,4.8 � 2.7 cm) (Table I). All donor defects wereclosed primarily. There were no problems withthe marginal mandibular branch of the facialnerve. Venous congestion was observed on thesecond postoperative day in only one flap andsubsided spontaneously. All flaps survived com-pletely. Dilute barium radiography performed3 weeks after the operation showed normalcontinuity of the upper digestive tract in allpatients. Two case reports are presented.

CASE REPORTS

Case 1A 73-year-old man had previously undergone laryngec-

tomy. A complication of his laryngectomy was a pharyngo-cutaneous fistula (Fig. 1). There was no evidence of recurrenttumor. The operation was performed under light sedationand local anesthesia. After the inner side watertight closurewas performed using the local tissue around the fistula, a 2.5� 4.5-cm cutaneous defect was created. A 3�5-cm submentalisland flap was planned and elevated on the right side sub-mental vessels (Fig. 1, above, right). The flap was then passedto the defect through a subcutaneous tunnel for the secondlayer closure. (Fig. 1, below). The donor site was closed pri-marily. The postoperative course was uncomplicated. The

TABLE IPatient and Flap Data

PatientAge(yr) Primary Lesion

Flap Size(cm) Complications

Postoperative Stay(days)

Oral IntakeDays

Follow-UpDuration (yr)

1 61 Larynx 5 � 3 None 1 22 42 57 Larynx 4 � 3 None 2 21 43 73 Larynx 5 � 3 None 1 23 34 62 Larynx 6 � 3 None 1 22 35 68 Larynx 4.5 � 3 None 1 24 36 72 Larynx 6 � 3 None 3 23 27 58 Larynx 4 � 2 None 1 22 18 75 Larynx 5 � 2 None 2 21 19 59 Larynx 4 � 3 None 1 24 1/2

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patient was discharged from the hospital with continued tubefeeding on the first postoperative day. Three weeks postop-eratively, a dilute barium radiograph showed a patent upperdigestive tract, and the patient was started on a clear diet (Fig.2). A mechanical soft diet was started in the fourth postop-erative week without evidence of fistula or stenosis (Fig. 3).

Case 2A 68-year-old man suffered from a pharyngocutaneous

fistula that occurred immediately after total laryngectomy atanother center. When we first examined the patient, thefistula measured 0.9 � 2.3 cm (Fig. 4, left). We decided to usea submental island flap for fistula repair. The operative pro-cedure was similar to that used in case 1. After closure of theinner surface of the pharynx, a 2.5 � 4-cm cutaneous defectwas created and a 3 � 4.5-cm submandibular island flap wasraised on the right side submental artery. The flap was passedthrough a subcutaneous tunnel for second-layer closure. No

complication was observed in the postoperative period. Thepatient was discharged on the first postoperative day with anasoesophageal feeding tube. A clear diet was given orally 3weeks after the operation and no fistula and stenosis wasrevealed by dilute barium radiography (Fig. 4, center). Fourweeks postoperatively, a mechanical soft diet was started (Fig.4, right).

DISCUSSION

Postoperative pharyngocutaneous fistula is arelatively frequent complication of total laryn-gectomy that prolongs the hospitalization of 2to 3 weeks to many weeks or even months.1 Thecause of pharyngocutaneous fistula formationmay be linked directly to local tissue ischemiafollowed by infection and subsequent wound

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 submentalartery island flap based on the right side submental artery. (Below) Intraoperative view:elevation and transposition of the flap through the subcutaneous tunnel to the recipientsite after the inner side closure was performed.

40 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005

breakdown. Contributing factors include ad-vanced disease and poor nutritional status, asevidenced by decreased serum protein and he-moglobin levels. Radiotherapy together withwound infection is one of the main causes ofthis pathologic condition. A relationship be-tween fistula formation and neck dissection,coexisting systemic disease, and size and site oftumor has also been found.1,2,4,12–14

Small or medium-size fistulas, especially innonirradiated patients, usually close spontane-ously with conservative therapy. Early conserva-tive fistula management consists of adequatewound drainage, pressure dressing, frequentuse of suction catheters, antiseptic gauze pack-ing, minimal débridement, nasogastric feed-ings, and frequent antibiotic oral swishes toirrigate the fistula.1,2,15 Spontaneous closure isexpected in approximately two-thirds of thesepatients, especially those who have a small an-terior or laterally positioned fistula where thegreater portion of the neck wound is healed.1,2

When fistulas fail to close with conservativemeasures, débridement and flap closure areindicated. Surgical treatment is not yet stan-dardized and, at present, it is impossible toenvisage an ideal solution for repairing com-plex lesions. The reconstruction requires imag-ination and technical skill. Direct closure is notadequate for larger wounds, especially in radi-ation fields.

Local procedures such as rhomboid flaps,rotation and transposition flaps, and lateralcervical flaps have been used.2,4,12,16 However,because of the random pattern vascular supplyof these flaps, the failure rate has remainedhigh and the risk of tissue necrosis after neckdissection and heavy radiation discouragestheir 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 ofthe intercostal arteries, has long been the flapof choice for closure of large pharyngocutane-ous fistulas. However, it usually requires tworeconstructive procedures and leaves majoraesthetic sequelae.2,4,12,18

Sternocleidomastoid muscle flaps have beenused for closure of nonmalignant fistulas.17,19,20

The pectoralis major flap can be used with orwithout a skin island. However, it is very bulkyand is generally indicated in cases of largesubstance loss in the pharyngolaryngealarea.2,12,21

Janssen and Thimsen reported the use of afull-thickness flap involving the middle third ofthe lower lip based on the submental artery forfull-thickness closure of cervical esophagocuta-neous fistulas.17 However, the important draw-back to this procedure is the aesthetic changein the central third of the lower lip.

Fabrizio et al.12 reported the use of the fas-ciocutaneous island flap pedicled on the super-ficial temporalis artery for the reconstruction

FIG. 3. Final results of the first patient.

FIG. 2. Radiograph of the normal continuity of the upperdigestive tract 3 weeks after the operation.

Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS 41

of a pharyngocutaneous fistula in a patient.They used a skin graft for donor-site closure.

Other described techniques have to be con-sidered along with the use of free flaps. Freeintestinal flaps provide the ability to closelarger fistulas in a one-stage operation.22–24

However, these procedures can be quite exten-sive and can involve considerable risk.17

The free radial forearm flap is a suitablealternative for the reconstruction of pharyngo-cutaneous fistulas.25–28 Because it requires har-vesting from a second operative site, which istime consuming, it may leave a troublesomescar and has its inherent complications. Mor-bidity of the donor site is another factor forconsideration.29 –31 Another major problemwith this technique is that it necessitates sacri-fice of a major artery to the hand. Althoughproblems following division of the radial arteryare rare, some cases have been reported.32 It isalso very risky to use microsurgical techniquesbecause of functional and structural alterationof the local vascular pedicles after radiotherapyfor adjuvant treatment of head and neckcancer.12,17,33–37

The submental artery island flap is very ver-satile and durable for closure of facial de-fects.5–10 Using the principles originally de-scribed by Martin et al.,5 we have repairedpharyngocutaneous fistulas with the submentalisland flap. The submental artery is a consistent

branch of the facial artery. It supplies an ex-tensive area of the ipsilateral upper neck and avariable area across the midline. Because ofrich subcutaneous and subdermal anastomosesbetween the two submental arteries, the sub-mental artery island flap can be easily raised onone side pedicle successfully and rotated to thewhole homolateral face and neck. The surgicaladvantage of an axial flap, which has a recog-nizable arterial and venous circulation that thelong axis of the flap can follow and whichyields branches to the dermal-subdermalplexus, is clear. The blood supply of the skin ofthe head and neck in general is known to berich, and the vascularity of this flap specificallyis so good that we have no hesitation using theflap closure for pharyngocutaneous fistulas inheavily irradiated tissue.

The major drawback of this technique is aprevious bilateral neck dissection where bothof the facial arteries may have been killed.However, in patients who have undergone pre-vious ipsilateral neck dissections, the submen-tal artery island flap can be raised on the con-tralateral side pedicle successfully and insetinto the defect. In our five patients with previ-ous ipsilateral neck dissection, we used the sub-mental island flap based on the contralateralsite without any problem.

An elliptical flap designed around the fistulawas sufficient to repair the inner surface of the

FIG. 4. (Left) Appearance of the patient in case 2, who suffered from pharyngocutaneous fistula. (Center) Radiograph obtained3 weeks postoperatively showing the patent upper digestive tract of patient 2. (Right) Postoperative appearance, 6 months afterthe operation.

42 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005

pharynx, and the maximum submental islandflap size was 6 � 3 cm in our series. The skinterritory of the submental island flap can be aslarge as 10 � 16 cm, as documented by injec-tion studies.5,11 In patients with larger fistulas inwhich the skin around the fistula is not suffi-cient for inner surface closure, a flap prefabri-cation technique may be applied.38 However,the reconstruction is performed in two stages.In the first (prefabrication) stage, a submentalisland flap is elevated and an epithelial lining iscreated by placement of a non–hair-bearingskin graft on the inner surface of the flap. Aftercomplete graft take is accomplished, the pre-fabricated flap is transferred to the recipientsite. However, we have no experience with theprefabricated submental island flap for pharyn-gocutaneous fistula closure, and this can be thesubject of another clinical study.

This study has demonstrated that pharyngo-cutaneous fistula repair with the submental ar-tery island flap is a single-stage, safe, simple,and reliable technique. It has a shorter opera-tion time, blood loss is less, and the patient’srecovery time is reduced. The submental skinhas the same characteristics as neck tissue, con-sisting of thin, pliable tissue with a perfectcolor match. The technique gives satisfactoryresults to both donor and recipient sites andprovides a reasonable expectation for the pa-tient of having an appearance that is accept-able cosmetically, allowing him or her to lead arelatively normal life.

Zühtü Demir, M.D.Y. Dikmen Mah. Ürdün Cad. 45Sok. 16/4 (Aytekinler Apt)06700 Oran, Ankara, Turkeyzuhtudemir@hotmail.com

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