Repair of Pharyngocutaneous Fistulas with the
Submental Artery Island Flap
Zühtü Demir, M.D., Hifzi Velidedeoğlu, M.D., and Selim Çelebioğlu, M.D.
Ankara, Turkey
Pharyngocutaneous fistulas after total laryn-
gectomy are difficult to manage and are a cause
for significant morbidity to the patient. When
fistulas fail to close with conservative measures,
débridement and flap closure are indicated.
Although a number of techniques to repair
pharyngocutaneous fistulas are described, each
of these procedures has its drawbacks. The au-
thors have used the submental island flap to
close postoperative pharyngocutaneous fistulas
in nine male patients during the past 4 years.
The mean patient age was 65 years (range, 57
to 75 years). The submental island flap is based
on the submental artery, a branch of the facial
artery. The inner aspect of the fistula was ini-
tially formed using hinge flaps on the skin
around the fistula. Once a watertight closure
of inner side was created, the skin defect
was closed with the submental island flap.
The maximum flap size was 6 ⫻ 3 cm and the
minimum size was 4 ⫻ 2 cm (average, 4.8 ⫻
2.7 cm) in this series. Direct closure was
achieved at all donor sites. Patients were
followed for 6 months to 4 years. No major
complication was noted in the postopera-
tive period. All patients have successfully
recovered their swallowing function. The
submental island flap is safe, rapid, and
simple to elevate and leaves minimal donor-
site morbidity. The authors believe that this
technique is a good alternative in the
reconstruction of pharyngocutaneous fis-
tulas. Application of the technique and
results are discussed. (Plast. Reconstr.
Surg. 115: 38, 2005.)
From the Department of Plastic and Reconstructive Surgery, Social Security Foundation Ankara Research Hospital. Received for publication
August 29, 2003; revised January 26, 2004.
DOI: 10.1097/01.PRS.0000145941.51938.67
38
After surgery for conditions such as laryngeal
cancer or hypopharyngeal cancer, salivary pha-
ryngocutaneous fistulas are sometimes trouble-
some complications. In the literature, the fre-
quency of fistula formation varies from 2 to 66
percent.1–3 Patients suffer considerable pro-
longed morbidity including salivary leakage, pro-
tracted difficulties in deglutition, and delay in
postoperative irradiation when indicated. In gen-
eral, these problems occur in patients who are
compromised by malnutrition, advanced disease,
ischemic tissues secondary to irradiation, and in-
fection. The management of these fistulas is a
challenge for the surgeon and patient. Although
most fistulas are small and heal spontaneously,
larger fistulas require surgical reconstruction.
The surgical reconstruction requires imagination
and technical skill. A number of methods to close
such pharyngocutaneous fistulas are available.
Myocutaneous and free flaps have become the
standard of care for these fistulas. However, each
of these techniques has its drawbacks.4
The submental island flap, an axial pattern
flap first introduced by Martin et al. in 1993,5 is
a reliable source of skin in the reconstruction
of various head and neck defects. We have used
this flap for closing pharyngocutaneous fistulas
that have been created at or developed after
surgery. In this report, we present our clinical
experience with use of the submental artery
island flap for the reconstruction of pharyngo-
cutaneous fistulas.
PATIENTS AND METHODS
We have repaired nine pharyngocutaneous
fistulas using the submental island flap in the
past 4 years. All patients were men and had
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS
laryngeal cancer that required radiotherapy af-
ter laryngectomy. The mean age was 65 years
(range, 57 to 75 years) (Table I). The patients
underwent total laryngectomy and developed a
salivary pharyngocutaneous fistula after opera-
tion. Pressure dressing and primary repair
were attempted in all of the patients, though
without success.
Technique
Six patients were operated on under local
anesthesia with sedation. The others were op-
erated on under general anesthesia. The pa-
tient is placed in supine position with the head
and neck moderately extended. First, an ellip-
tical flap around the fistula is designed to re-
pair the inner surface of the pharynx. A skin
incision is made around the flap and the tissue
is undermined up to the point of the fistula.
The undermined skin edges of the ellipse are
then inverted in a trapdoor fashion, and su-
tures are placed in the subcutaneous fat to
create an inner squamous cell lining. This clo-
sure can be tested by having the patient swal-
low either methylene blue or grape juice. Once
a watertight closure is achieved, the submental
island flap is planned according to the cutane-
ous defect size. The detailed anatomy of the
submental island flap is presented else-
where.5–11 The upper limit of the flap is marked
just under the mandibular arc to avoid a visible
scar. After incising the borders of the flap, the
dissection is carried down through the
platysma muscle, with careful preservation of
the marginal mandibular nerves. The flap is
then elevated in an inferior fashion in the sub-
platysmal plane. The submental vessels are
identified near the inferior border of the man-
dible on the flap pedicle side. The flap is then
mobilized from the mandible, and the sub-
mental vessels can now be dissected back to the
facial vessels. Dissection can be carried down to
39
the origin of the facial vessels to achieve a long
pedicle. In this way, the submental artery island
flap is created. The flap is then tunneled to the
recipient site to the second layer closure. The
donor site closes directly without additional
dissection.
Three weeks postoperatively, a dilute barium
radiograph was obtained, the nasoesophageal
feeding tube was removed, and the patient was
started on a clear liquid diet. After 4 weeks,
they were placed on a mechanical soft diet.
RESULTS
The patients were observed for 6 months to
4 years. During this period, no major compli-
cation was noted and satisfactory results were
obtained. The maximum flap size was 6 ⫻ 3 cm
and the minimum size was 4 ⫻ 2 cm (average,
4.8 ⫻ 2.7 cm) (Table I). All donor defects were
closed primarily. There were no problems with
the marginal mandibular branch of the facial
nerve. Venous congestion was observed on the
second postoperative day in only one flap and
subsided spontaneously. All flaps survived com-
pletely. Dilute barium radiography performed
3 weeks after the operation showed normal
continuity of the upper digestive tract in all
patients. Two case reports are presented.
CASE REPORTS
Case 1
A 73-year-old man had previously undergone laryngec-
tomy. A complication of his laryngectomy was a pharyngo-
cutaneous fistula (Fig. 1). There was no evidence of recurrent
tumor. The operation was performed under light sedation
and local anesthesia. After the inner side watertight closure
was performed using the local tissue around the fistula, a 2.5
⫻ 4.5-cm cutaneous defect was created. A 3⫻5-cm submental
island flap was planned and elevated on the right side sub-
mental vessels (Fig. 1, above, right). The flap was then passed
to the defect through a subcutaneous tunnel for the second
layer closure. (Fig. 1, below). The donor site was closed pri-
marily. The postoperative course was uncomplicated. The

TABLE I
Patient and Flap Data

Age Flap Size Postoperative Stay Oral Intake Follow-Up

Patient (yr) Primary Lesion (cm) Complications (days) Days Duration (yr)

1 61 Larynx 5⫻3 None 1 22 4

2 57 Larynx 4⫻3 None 2 21 4
3 73 Larynx 5⫻3 None 1 23 3
4 62 Larynx 6⫻3 None 1 22 3
5 68 Larynx 4.5 ⫻ 3 None 1 24 3
6 72 Larynx 6⫻3 None 3 23 2
7 58 Larynx 4⫻2 None 1 22 1
8 75 Larynx 5⫻2 None 2 21 1
9 59 Larynx 4⫻3 None 1 24 1/2
40 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005

FIG. 1. (Above, left) The first patient with pharyngocutaneous fistula before the oper-
ation. (Above, right) Skin markings for the elliptical flap around the fistula and submental
artery island flap based on the right side submental artery. (Below) Intraoperative view:
elevation and transposition of the flap through the subcutaneous tunnel to the recipient
site after the inner side closure was performed.

patient was discharged from the hospital with continued tube
feeding on the first postoperative day. Three weeks postop-
eratively, a dilute barium radiograph showed a patent upper
digestive tract, and the patient was started on a clear diet (Fig.
2). A mechanical soft diet was started in the fourth postop-
erative week without evidence of fistula or stenosis (Fig. 3).
Case 2
A 68-year-old man suffered from a pharyngocutaneous
fistula that occurred immediately after total laryngectomy at
another center. When we first examined the patient, the
fistula measured 0.9 ⫻ 2.3 cm (Fig. 4, left). We decided to use
a submental island flap for fistula repair. The operative pro-
cedure was similar to that used in case 1. After closure of the
inner surface of the pharynx, a 2.5 ⫻ 4-cm cutaneous defect
was created and a 3 ⫻ 4.5-cm submandibular island flap was
raised on the right side submental artery. The flap was passed
through a subcutaneous tunnel for second-layer closure. No
complication was observed in the postoperative period. The
patient was discharged on the first postoperative day with a
nasoesophageal feeding tube. A clear diet was given orally 3
weeks after the operation and no fistula and stenosis was
revealed by dilute barium radiography (Fig. 4, center). Four
weeks postoperatively, a mechanical soft diet was started (Fig.
4, right).
DISCUSSION
Postoperative pharyngocutaneous fistula is a
relatively frequent complication of total laryn-
gectomy that prolongs the hospitalization of 2
to 3 weeks to many weeks or even months.1 The
cause of pharyngocutaneous fistula formation
may be linked directly to local tissue ischemia
followed by infection and subsequent wound
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS
FIG. 2. Radiograph of the normal continuity of the upper
digestive tract 3 weeks after the operation.
FIG. 3. Final results of the first patient.
breakdown. Contributing factors include ad-
vanced disease and poor nutritional status, as
evidenced by decreased serum protein and he-
moglobin levels. Radiotherapy together with
wound infection is one of the main causes of
this pathologic condition. A relationship be-
tween fistula formation and neck dissection,
coexisting systemic disease, and size and site of
tumor has also been found.1,2,4,12–14
41
Small or medium-size fistulas, especially in
nonirradiated patients, usually close spontane-
ously with conservative therapy. Early conserva-
tive fistula management consists of adequate
wound drainage, pressure dressing, frequent
use of suction catheters, antiseptic gauze pack-
ing, minimal débridement, nasogastric feed-
ings, and frequent antibiotic oral swishes to
irrigate the fistula.1,2,15 Spontaneous closure is
expected in approximately two-thirds of these
patients, especially those who have a small an-
terior or laterally positioned fistula where the
greater portion of the neck wound is healed.1,2
When fistulas fail to close with conservative
measures, débridement and flap closure are
indicated. Surgical treatment is not yet stan-
dardized and, at present, it is impossible to
envisage an ideal solution for repairing com-
plex lesions. The reconstruction requires imag-
ination and technical skill. Direct closure is not
adequate for larger wounds, especially in radi-
ation fields.
Local procedures such as rhomboid flaps,
rotation and transposition flaps, and lateral
cervical flaps have been used.2,4,12,16 However,
because of the random pattern vascular supply
of these flaps, the failure rate has remained
high and the risk of tissue necrosis after neck
dissection and heavy radiation discourages
their use.1,2,4,12,17
The Bakamjian flap, elevated from the del-
topectoral region based on an axial vascular-
ization coming from cutaneous branches of
the intercostal arteries, has long been the flap
of choice for closure of large pharyngocutane-
ous fistulas. However, it usually requires two
reconstructive procedures and leaves major
aesthetic sequelae.2,4,12,18
Sternocleidomastoid muscle flaps have been
used for closure of nonmalignant fistulas.17,19,20
The pectoralis major flap can be used with or
without a skin island. However, it is very bulky
and is generally indicated in cases of large
substance loss in the pharyngolaryngeal
area.2,12,21
Janssen and Thimsen reported the use of a
full-thickness flap involving the middle third of
the lower lip based on the submental artery for
full-thickness closure of cervical esophagocuta-
neous fistulas.17 However, the important draw-
back to this procedure is the aesthetic change
in the central third of the lower lip.
Fabrizio et al.12 reported the use of the fas-
ciocutaneous island flap pedicled on the super-
ficial temporalis artery for the reconstruction
42
FIG. 4. (Left) Appearance of the patient in case 2, who suffered from pharyngocutaneous fistula. (Center) Radiograph obtained
3 weeks postoperatively showing the patent upper digestive tract of patient 2. (Right) Postoperative appearance, 6 months after
the operation.
of a pharyngocutaneous fistula in a patient.
They used a skin graft for donor-site closure.
Other described techniques have to be con-
sidered along with the use of free flaps. Free
intestinal flaps provide the ability to close
larger fistulas in a one-stage operation.22–24
However, these procedures can be quite exten-
sive and can involve considerable risk.17
The free radial forearm flap is a suitable
alternative for the reconstruction of pharyngo-
cutaneous fistulas.25–28 Because it requires har-
vesting from a second operative site, which is
time consuming, it may leave a troublesome
scar and has its inherent complications. Mor-
bidity of the donor site is another factor for
consideration.29 –31 Another major problem
with this technique is that it necessitates sacri-
fice of a major artery to the hand. Although
problems following division of the radial artery
are rare, some cases have been reported.32 It is
also very risky to use microsurgical techniques
because of functional and structural alteration
of the local vascular pedicles after radiotherapy
for adjuvant treatment of head and neck
cancer.12,17,33–37
The submental artery island flap is very ver-
satile and durable for closure of facial de-
fects.5–10 Using the principles originally de-
scribed by Martin et al.,5 we have repaired
pharyngocutaneous fistulas with the submental
island flap. The submental artery is a consistent
PLASTIC AND RECONSTRUCTIVE SURGERY, January 2005
branch of the facial artery. It supplies an ex-
tensive area of the ipsilateral upper neck and a
variable area across the midline. Because of
rich subcutaneous and subdermal anastomoses
between the two submental arteries, the sub-
mental artery island flap can be easily raised on
one side pedicle successfully and rotated to the
whole homolateral face and neck. The surgical
advantage of an axial flap, which has a recog-
nizable arterial and venous circulation that the
long axis of the flap can follow and which
yields branches to the dermal-subdermal
plexus, is clear. The blood supply of the skin of
the head and neck in general is known to be
rich, and the vascularity of this flap specifically
is so good that we have no hesitation using the
flap closure for pharyngocutaneous fistulas in
heavily irradiated tissue.
The major drawback of this technique is a
previous bilateral neck dissection where both
of the facial arteries may have been killed.
However, in patients who have undergone pre-
vious ipsilateral neck dissections, the submen-
tal artery island flap can be raised on the con-
tralateral side pedicle successfully and inset
into the defect. In our five patients with previ-
ous ipsilateral neck dissection, we used the sub-
mental island flap based on the contralateral
site without any problem.
An elliptical flap designed around the fistula
was sufficient to repair the inner surface of the
Vol. 115, No. 1 / REPAIR OF PHARYNGOCUTANEOUS FISTULAS
pharynx, and the maximum submental island
flap size was 6 ⫻ 3 cm in our series. The skin
territory of the submental island flap can be as
large as 10 ⫻ 16 cm, as documented by injec-
tion studies.5,11 In patients with larger fistulas in
which the skin around the fistula is not suffi-
cient for inner surface closure, a flap prefabri-
cation technique may be applied.38 However,
the reconstruction is performed in two stages.
In the first (prefabrication) stage, a submental
island flap is elevated and an epithelial lining is
created by placement of a non– hair-bearing
skin graft on the inner surface of the flap. After
complete graft take is accomplished, the pre-
fabricated flap is transferred to the recipient
site. However, we have no experience with the
prefabricated submental island flap for pharyn-
gocutaneous fistula closure, and this can be the
subject of another clinical study.
This study has demonstrated that pharyngo-
cutaneous fistula repair with the submental ar-
tery island flap is a single-stage, safe, simple,
and reliable technique. It has a shorter opera-
tion time, blood loss is less, and the patient’s
recovery time is reduced. The submental skin
has the same characteristics as neck tissue, con-
sisting of thin, pliable tissue with a perfect
color match. The technique gives satisfactory
results to both donor and recipient sites and
provides a reasonable expectation for the pa-
tient of having an appearance that is accept-
able cosmetically, allowing him or her to lead a
relatively normal life.
Zühtü Demir, M.D.
Y. Dikmen Mah. Ürdün Cad. 45
Sok. 16/4 (Aytekinler Apt)
06700 Oran, Ankara, Turkey
zuhtudemir@hotmail.com
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