Critical Oropharyngocutaneous Fistulas after Microsurgical Head and Neck Reconstruction: Indications for Management Using the ???Tissue-Plug??? Technique

Abstract

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.

The submental flap for oral cavity reconstruction: Extended indications and technical refinements

“…It provides a relatively thin, well vascularized piece of tissue in a single stage operation, and obviates the need for a second stage to divide the pedicle, or sophisticated microsurgical techniques. It has been used after infection, trauma, or tumor extirpation for reconstruction of the mustache and beard area [9], the nose,[10] the pharynx,[11],[12] the palate,[13] and the middle and lower face [13-15]. However up to our knowledge its use in composite intra-oral defects has not been reported before in the western literature.…”

Bowel Preparation before Microvascular Free Colon Transfer for Head and Neck Reconstruction: Is It Necessary?

“…One patient developed a pharyngocutaneous fistula at the upper colon anastomosis that was repaired using a pectoralis major muscle flap used as a "tissue plug." 17 One patient developed a superficial abdominal wound infection and 5 cm of the upper end of the incision was opened and wet-to-dry dressing changes were performed. The wound healed after several days.…”

Reconstruction of the lip commissure with upper and lower lip full thickness defects using submental and nasolabial flaps: A case report

“…The earliest reported use of this flap for reconstruction in oral carcinoma was by Sterneand Hall in 1996. Since it was described, the flap has been extensively used for reconstruction of small to moderate size oral cavity soft tissue defects 21,22,23,24,25 . However, its role in lip, lip commisure defects reconstruction has not been clearly described.…”