Hinge Flap with Triangular Extension for Reconstruction of Pharyngocutaneous and Laryngocutaneous Fistulas

Abstract

Hinge flaps are commonly used for closure of a pharyngocutaneous fistula (PCF) or laryngocutaneous fistula. These flaps are employed to augment the wall of the pharynx or larynx, but the junction between the reconstructed and native lumens can eventually become narrow and irregular after reconstruction with standard hinge flaps. We devised a method of adding a triangular extension to the end of either or both flaps and used it to treat 3 patients. In 1 patient who developed a PCF (4 × 10 cm) after laryngectomy followed by radiotherapy, the fistula was closed with 2 hinge flaps. One flap had a caudal triangular extension. The residual skin defect was covered by a pedicled latissimus dorsi musculocutaneous flap. Another patient who developed a PCF (2.5 × 3 cm) after laryngectomy underwent 2-stage reconstruction using a buccal mucosal graft with a triangular extension, followed by 2 hinge flaps. A patient who developed an laryngocutaneous fistula (1 × 2 cm) after radiotherapy and subsequent partial laryngectomy underwent reconstruction using 2 hinge flaps, each of which had a triangular extension. The skin defect was covered by another flap. Postoperative CT or video fluoroscopic examination of swallowing showed a smooth lumen with no strictures in all 3 patients. The triangular extension of the hinge flap supplements the pharyngeal/laryngeal wall at the junction between the reconstructed and intact regions, thus avoiding postoperative stricture. Especially with PCF reconstruction, restoration of a smooth luminal surface minimizes dysphagia.

Fig. 1.

Outline of 2 hinge flaps with triangular extensions (*). Bilateral triangular extensions are shown, but a unilateral extension could be an alternative. The base of the triangular extension has the same width as the hinge flap at their junction, while the length should be about 1.5 times its width.

Video Graphic 1.

See video, Supplemental Digital Content 1, which displays 3D animation of the procedure.

Fig. 2.

An 86-year-old man with a PCF after laryngectomy. A, A caudal triangular extension (base, 3 cm; length, 4 cm) has been added to the left hinge flap (width, 4 cm). The pharynx will be incised along the red dotted line to insert the extension flap. B, Raising the hinge flap and triangular extension. The blue circle indicates the triangular extension and the site of its insertion into the incised pharynx. A latissimus dorsi musculocutaneous flap to cover the skin defect can be seen above. C, Postoperative fluoroscopic examination of swallowing (6 weeks after reconstruction) showed no strictures and smooth reconstruction of the lumen (yellow arrows).