Risk Factors of and Treatments for Pharyngocutaneous Fistula Occurring after Oropharynx and Hypopharynx Reconstruction

BACKGROUND: A pharyngocutaneous fistula is a common and difficult-to-manage complication after head and neck reconstruction. It can lead to serious complications such as flap failure, carotid artery rupture, and pharyngeal stricture, and may require additional surgery. Previous radiotherapy, a low serum albumin level, and a higher T stage have been proposed as contributing factors. We aimed to clarify the risk factors for pharyngocutaneous fistula in patients who underwent flap reconstruction and to describe our experiences in treating pharyngocutaneous fistula. METHODS: Squamous cell carcinoma cases that underwent flap reconstruction after cancer resection from 1995 to 2013 were analyzed retrospectively. We investigated several significant clinical risk factors. The treatment modality was selected according to the size of the fistula and the state of the surrounding tissue, with options including conservative management, direct closure, flap surgery, and pharyngostoma formation. RESULTS: A total of 127 cases (18 with fistulae) were analyzed. A higher T stage (P=0.048) and tube-type reconstruction (P=0.007) increased fistula incidence; other factors did not show statistical significance (P>0.05). Two cases were treated with conservative management, 1 case with direct closure, 4 cases with immediate reconstruction using a pectoralis major musculocutaneous flap, and 11 cases with direct closure (4 cases) or additional flap surgery (7 cases) after pharyngostoma formation. CONCLUSIONS: Pharyngocutaneous fistula requires global management from prevention to treatment. In cases of advanced-stage cancer and tube-type reconstruction, a more cautious approach should be employed. Once it occurs, an accurate diagnosis of the fistula and a thorough assessment of the surrounding tissue are necessary, and aggressive treatment should be implemented in order to ensure satisfactory long-term results.

Hand Reconstruction Using Medialis Pedis and Medial Plantar Chimeric Free Flap

It is not easy to decide whether covering soft tissue defect occurred in multiple adjacent fingers with a single, large flap and later secondary division of fingers or cover each digits independently in hand reconstruction. The authors reconstructed soft tissue defect of left second and third finger with medial plantar artery based medialis pedis and medial plantar chimeric free flap and it enabled early rehabilitation without secondary surgery to divide each fingers and get satisfactory result.

Reconstruction of the Hand Using Fabricated Great Toe Pulp and Anterolateral Thigh Chimeric Free Flap

In the treatment of large hand soft tissue defect including pulp defect, it has been recommended to reconstruct pulp defect separately by glabrous skin flap such as toe pulp free flap or thenar free flap considering of skin texture, color and sensation. But sometimes we may not use recipient digital artery which is required for microanastomosis because of the injury of digital artery. To solve this problem, the authors reconstructed thumb pulp and hand palmar area soft tissue defect with fabricated flow-through chimeric free flap connecting distal part of descending branch of lateral circumflex femoral artery which distributes perforators of anterolateral thigh free flap and pedicle of great toe pulp free flap and met with good results.

Heterotopic Ossification in Post-Burn Scar Contracture of the Wrist

Heterotopic ossification is one of the well known complications related to burn and mainly involves major joints and lower extremity, but heterotopic ossification of the hand has been rarely reported. The authors experienced treatment of heterotopic ossification in post-burn scar contracture of the wrist by wide excision with full thickness skin graft and there was no complication such as recurrence. As heterotopic ossification with ulceration is hard to cure with conservative treatment, it must be removed completely by surgical treatment. If ulceration in burn scar of the hand doesn't heal with the conservative treatment, differential diagnosis of heterotopic ossification will be made first.