Invited Discussion

Those of us who trained in plastic surgery in the 1970s are familiar with a host of debilitating iatrogenic conditions resulting from radical head and neck cancer extirpation followed by local repair and radiotherapy. These included the so-called Andy-Gump deformity, named after a 1930s comic book character who appeared to have no lower jaw (Figs. [1A], [1B]). The condition followed composite resection of the central “C” segment[1] of the mandible, aggressive adjunctive radiation with failed osseous reconstruction, and resulted in socially inhibiting oral incontinence. Osteoradionecrosis of the mandible also followed irradiation, with or without surgery. When extensive, it produced trismus, loss of dentition, unbearable pain, opiate dependence, and social isolation (Fig. [2]).

Figure 1 (A) Cartoon of Andy Gump. (B) Andy Gump deformity due to loss of the central “C” segment of the mandible. The patient had a complete loss of oral continence.

Figure 2 Panorex of a mandible showing extensive osteoradionecrosis. Note the “moth-eaten appearance.” The patient had trismus, was in severe pain, and was addicted to opiates.

A third in this triumvirate of misery (Fig. [3]) was the massive pharyngocutaneous fistula (not to be confused with small fistulous anastomotic leaks, which may be treated conservatively). This, too, often followed surgery (laryngectomy) and irradiation. A subtotal breakdown or loss of the hypopharyngeal wall left a large anterior opening - far too large to heal spontaneously. Furthermore, it was not only debilitating, resistant to conventional treatment and a surgical disaster; but, like the other two, imposed a severe social and financial toll on the patient, the family, the health care system, and society at large.

Figure 3 Postoperative result of repair of a pharyngocutaneous fistula using a free jejunum opened down the antimesenteric border as a patch for lining, and a pectoralis musculocutaneous flap for overlapping cover. The result is rather bulky, but the outcome successful.

These complications are now routinely handled by microvascular procedures and in many cases are prevented by the primary use of the reconstructive techniques with which the pages of this journal are replete. However, in a primary pharyngeal reconstruction, if these modalities were to fail, the result would still be a large pharyngocutaneous fistula.

As in most reconstructive problems, the evolution of operative techniques to treat pharyngocutaneous fistulae closely shadows the historical development of plastic surgery and reconstructive microsurgery. From the random Wookey turnover flaps,[2] [3] to the axial deltopectoral flap,[4] [5] to the pectoralis musculocutaneous flap,[6] [7] to the double layer free flap,[8] [9] to the jejunal flap,[10] [11] to the anterior lateral thigh perforator flap,[12] and to various combinations thereof,[13] [14] [15] [16] the whole panoply of the evolving specialty is graphically represented. Yet it is fair to say that there is still no standardized, agreed upon way to handle the massive pharyngocutaneous fistula. The large number of procedures described testifies not only to the relative rarity of the condition but also to the lack of consensus among those treating it.

Nevertheless, it is an old but sound principle that insists on replacing “like with like.” Many of the techniques rely on smothering the fistula with well-vascularized but bulky muscle, or other well-vascularized soft tissue. Multi-layer repairs are favored. The results, although effective, frequently leave the patient with an ungainly mass in the anterior neck depending upon his or her build (Fig. [4]). The excessive tissue can even produce respiratory obstruction by prolapsing over the tracheostome. Normal anterior neck tissue is relatively thin and supple - difficult to reproduce with a folded flap or combination of flaps.

Figure 4 Effective results but with ungainly mass in anterior neck.

The authors propose a cutaneous repair of the mucosal defect using a single skin paddle radial forearm flap, but rely on sealing the defect by opposing de-epithelialized surfaces around the central epithelial repair. The principle of overlap is a good one. The two de-epithelialized surfaces should reliably stick together and form a sound peripheral seal. The risk of inclusion of cyst formation, although theoretical, is probably not a major practical consideration. It would certainly benefit the patient if the principle of overlap be used whenever possible whatever method is employed. For instance, in the case of a double-paddle radial forearm flap, the outer flap should be larger than the inner one and should ideally overlap onto the native neck skin, which may be denuded of epithelium to receive it. The second flap thereby overlies and reinforces the suture line of the first.

The authors minimize bulk by skin-grafting the exposed underbelly of the forearm flap. Many plastic surgeons would feel happier with a solid external cutaneous closure where skin is sutured to skin. This certainly permits easy monitoring of the flap and avoids the somewhat unsatisfactory application of a skin graft to fat or fascia, or indeed the radial artery. However, the risk of the tissue prolapsing over the tracheostome is much less likely with a (contracted) skin graft than it is with a pendulous, fatty, cutaneous skin paddle.

The only other technique likely to guarantee a bulk-free closure is the one reported by Carlson et al.[11] This method utilizes a partitioned jejunal flap with a piece of de-mucosalized jejunal wall skin skin-grafted to form the outer layer. However, this is best employed in the setting of tubular pharyngeal reconstruction using an attached jejunal segment. It would be difficult to justify an intra-abdominal procedure otherwise.

In summary, the authors report a relatively simple, single, unfolded flap technique for the closure of massive pharyngocutaneous fistulae. It has numerous advantages over folded or two-flap techniques, particularly in terms of minimizing donor morbidity and in avoiding bulk. The tissue is well-vascularized and the overlapping closure should minimize the risk of recurrence and produce a stable reconstruction.

REFERENCES

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