Two patients with PCF and 1 patient with LCF were treated by the above procedure. Patient management was performed in compliance with recognized national standards and the principles of the Declaration of Helsinki.
The first patient developed a PCF (4 × 10 cm) 3 weeks after undergoing laryngectomy followed by radiotherapy. Six weeks later, the fistula was closed with 2 hinge flaps, 1 of which had a caudal triangular extension. Then the skin defect was covered by using a pedicled latissimus dorsi musculocutaneous flap (Fig. 2). The second patient developed a PCF (2.5 × 3 cm) 3 weeks after laryngectomy without radiotherapy and underwent 2-stage reconstruction. Ten weeks later, buccal mucosa (3 × 5 cm) was grafted to the right side of the fistula at the first operation. The mucosal graft was designed so that it could later be fashioned into a hinge flap with a caudal triangular extension. Two weeks after the first surgery, the graft and subgraft tissue were elevated as a mucosal flap, turned inward to close the fistula, and sutured. The residual skin defect was closed by direct suturing. The third patient had an LCF (1 × 2 cm) due to partial laryngectomy following radiotherapy and underwent reconstruction using 2 hinge flaps with triangular extensions at 6 months after development of the fistula. One triangular extension was located at the superior end of the right flap and the other extension was at the inferior end of the left flap. The skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. When computed tomography or video fluoroscopic examination of swallowing was performed at least 3 weeks after reconstruction, a smooth lumen with no stricture was seen in all 3 patients.
PCF is a common complication after surgical treatment of cervical malignancies, and there have been numerous reports about methods for closing these fistulas.6–18 The hinge flap procedure, in which bilateral skin flaps raised alongside the PCF are turned in to line the pharynx, was described in a plastic surgery textbook published in 1948.1 This procedure effectively augments the wall of the pharynx at the midsection of the reconstructed region, but stenosis and gaps can occur, especially at the caudal end of the flap due to circumferential contracture of the fistula that occurs while waiting for flap maturation. To obtain a smooth anastomosis between the flap and intact tissue, the circumferential contracture should be divided and another flap should be inserted to fill the defect. Adding a triangular extension to a hinge flap serves this purpose effectively. If the triangular extension is considered to be an isosceles triangle with its base at the upper or the lower margin of a hinge flap, the circumference of the reconstructed lumen can theoretically be increased by the width of the triangle’s base. The triangular extension also allows reconstruction of a smooth luminal surface in the caudal direction, so that dysphagia is minimized.
A smooth luminal surface is less important with LCF reconstruction compared with PCF reconstruction,19 but postoperative stricture is more problematic, so the triangular extension may have a greater importance in LCF reconstruction.
The triangular extension should be connected to the main flap without crossing any scars from previous surgery. If care is taken to ensure that the extension is not too thin, it should receive sufficient blood flow and remain viable like the main flap. Because the triangular extension moves together with the hinge flap and there is no torsion or warping, unlike a transposition flap, it promotes creation of a smooth lumen. Accordingly, we suggest that adding a triangular extension should be strongly considered in most patients undergoing PCF/LCF reconstruction with hinge flaps.
When PCF or LCF reconstruction is performed, adding a triangular extension to a hinge flap increases the luminal diameter at the anastomosis between the reconstructed and normal regions, avoiding postoperative stricture. Especially with PCF reconstruction, the triangular extension provides a smooth luminal surface that minimizes dysphagia.
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