Management of radiation-induced tracheocutaneous tissue defects by transplantation of an ear cartilage graft and deltopectoral flap

The U- advancement Burrow's Flap in Persistent Tracheocutaneous Fistula. ~ Case Report

Persistent tracheo-cutaneous fistulae necessitate a closure with pedicled or free flaps. The modality adopted is to reconstitute the anterior tracheal wall without compromising the tracheal lumen. We have developed the lateral U advancement Burrow's flap over the strap muscles and tracheal lateral fibrous flaps, to repair a large trachea-cutaneous fistula.

Comparison Between Flap and Primary Closures of Persistent Tracheocutaneous Fistula: A Scoping Review

Objectives: To compare the susceptibility and complication rates between flap and primary closures for tracheocutaneous fistula (TCF). Methods: We searched 4 online databases (Web of Science, Cochrane Library, PubMed, and Scopus) for relevant articles published from study inception until August 2022. Studies including at least 5 adult or child patients with persistent TCFs who underwent closure surgery via primary or flap repair were included. All included studies reported outcomes of surgical repairs such as successful closure rates and complications. In addition, we performed single-arm meta-analyses for each surgical method using the Open Meta-Analyst software to calculate the pooled event rate with a 95% confidence interval (CI); compared the 2 surgical procedures using the Review Manager software using the risk ratio with 95% CI; and assessed study quality based on the National Heart, Lung, and Blood Institute criteria. Results: Overall, 27 studies with 997 patients were included. No significant difference was observed between the closure success and major complication rates of surgical methods. The primary and flap closures had overall success rates of 0.979 and 0.98, respectively. The overall major complication rates in primary and flap closures were 0.034 and 0.021, respectively; and that of minor were 0.045 and 0.04, respectively. In primary closure, a significant decrease in the success rate with increasing age at the time of decannulation was observed. In addition, the risk of major complications increased with increasing time from decannulation to closure. Conclusions: Both the primary and flap repairs of TCF are effective based on closure success and complication rates; therefore, they are both acceptable therapeutic alternatives, and flap repair can be considered when other techniques have failed. However, further prospective randomized studies comparing these 2 procedures are needed to support our results.

Ionizing radiation exposure of stem cell-derived chondrocytes affects their gene and microRNA expression profiles and cytokine production

Human induced pluripotent stem cells (hiPSCs) can be differentiated into chondrocyte-like cells. However, implantation of these cells is not without risk given that those transplanted cells may one day undergo ionizing radiation (IR) in patients who develop cancer. We aimed to evaluate the effect of IR on chondrocyte-like cells differentiated from hiPSCs by determining their gene and microRNA expression profile and proteomic analysis. Chondrocyte-like cells differentiated from hiPSCs were placed in a purpose-designed phantom to model laryngeal cancer and irradiated with 1, 2, or 3 Gy. High-throughput analyses were performed to determine the gene and microRNA expression profile based on microarrays. The composition of the medium was also analyzed. The following essential biological processes were activated in these hiPSC-derived chondrocytes after IR: "apoptotic process", "cellular response to DNA damage stimulus", and "regulation of programmed cell death". These findings show the microRNAs that are primarily responsible for controlling the genes of the biological processes described above. We also detected changes in the secretion level of specific cytokines. This study demonstrates that IR activates DNA damage response mechanisms in differentiated cells and that the level of activation is a function of the radiation dose.

Decision algorithm and surgical strategies for managing tracheocutaneous fistula

Background

Persistent tracheocutaneous fistula (TCF) is a complication of prolonged use of tracheostomy tube. Although many procedures exist to correct this issue, there is no consensus regarding its optimal management. We constructed a decision algorithm to determine appropriate surgical strategies for TCF repair.

Methods

Retrospectively reviewing our hospital’s records, we found fourteen consecutive patients who had received surgical repair of tracheocutaneous fistula (primary closure or advanced local flap) between February 2013 and December 2018 and collected data relevant to their cases.

Results

We identified 11 male and 3 female patients. Duration of tracheostomy dependence was 8.1±4.7 months, and timespan from decannulation to surgical closure 7.4±6.5 months. Seven patients received primary closures, six received hinged turnover flaps, and one received random and perforator flap reconstruction. There was no perioperative mortality or morbidity except for one patient requiring a repeat tracheostomy 11 months after TCF repair due to pneumonia and subsequent respiratory failure. We used our findings and those reported in the literature to construct a modified risk factor scoring system based on patient’s physical status, major comorbidities, perifistular soft tissue condition, and nutritional status and an algorithm for managing TCF based on the patients’ fistula size and modified risk factor scores.

Conclusions

In conclusion, we were able to review our cases and those of other studies to create a risk scoring system and a decision algorithm that we believe will help optimize patient-directed surgical management of TCF repair.

Closure of tracheocutaneous fistula using prefabricated conchal bowl cartilage and a supraclavicular flap

BACKGROUND

Tracheocutaneous fistula represents one of the most troublesome complications of prolonged tracheostomy. Simple closure of a fistula can be ineffective, particularly in the context of prior surgery and adjuvant radiation. As such, modes of repair have expanded to include locoregional flaps and even free tissue transfers.

OBJECTIVE

This paper describes a case of persistent tracheocutaneous fistula in an irradiated patient who had undergone previous unsuccessful attempts at repair.

METHOD AND RESULTS

The use of regional fasciocutaneous supraclavicular flap with prefabricated conchal bowl cartilage resulted in successful closure of the tracheocutaneous fistula.

CONCLUSION

This represents a novel technique for closure of such fistulas in patients for whom previous attempts have failed. This mode of repair should be added to the surgeon's repertoire of reparative techniques.

Tracheocutaneous Fistula Closure: Comparison of Rhomboid Flap Repair with Z Plasty Repair in a Case Series of 40 Patients

INTRODUCTION

Tracheocutaneous fistula (TCF) is one of the recognized sequelae of a long-term tracheostomy resulting from mucocutaneous overgrowth which prevents closure of the artificial lumen at the site of tracheostomy. Primary closure of TCF has disappointing results and may lead to complications like pneumothorax, pneumomediastinum, cervicofacial subcutaneous emphysema, and depressed scar.

OBJECTIVE

To compare TCF repair using fistulectomy followed by rhomboid flap versus fistulectomy followed by Z plasty repair.

METHODS

In this prospective study, 40 patients of either sex with persistent TCF were included. All patients were randomly divided into two groups. Group I had 20 patients who underwent TCF repair using a technique in which fistulectomy was done followed by its closure in layers, and finally closing the defect using a rhomboid flap. The remaining 20 were included in group II who underwent TCF repair using a technique in which fistulectomy was done followed by layered closing, and final closure of the defect was done using Z plasty. The follow-up period was 3 months.

RESULTS

Out of 40 patients, all but 8 experienced a successful outcome without any complications, and complete aesthetic satisfaction, with improvement in phonation, and no soiling of clothes with mucus or sputum. The 8 unsuccessful patients belonged to group II (Z plasty group).

CONCLUSION

Both techniques have been described in the literature and are proven to give good results. Our study emphasizes the fact that in our experience, the rhomboid flap was a better alternative for TCF repair than Z plasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The use of a prefabricated radial forearm free flap for closure of a large tracheocutaneous fistula: a case report and review of the literature

INTRODUCTION

The closure of complex tracheocutaneous fistulae is a surgical challenge. We describe a staged approach for management of a patient with a large tracheocutaneous fistula in the setting of prior surgery and local radiation therapy.

CASE PRESENTATION

A 66-year-old Caucasian man who had undergone prior surgery and radiation therapy to the lower neck presented to our hospital for treatment of a large tracheocutaneous fistula that had developed with an adjacent area of tracheal stenosis. A prefabricated composite graft made up of an inner mucosal lining (buccal mucosa), a central cartilage structure (conchal cartilage), and external skin lining was constructed on the patient's distal volar forearm and subsequently harvested in a staged fashion. This graft was transferred as a free flap and successfully used to close the patient's defect following revascularization. Sixty months after surgery, the patient had no airway compromise or new dysphonia.

CONCLUSIONS

The use of a prefabricated mucosally lined composite graft can allow for successful closure of large tracheocutaneous fistulae, even in the setting of prior radiation therapy.

A persistent tracheocutaneous fistula closed with two hinged skin flaps and rib cartilage interpositional grafting

Persistent tracheal fistula after tracheostomy decannulation is a recognized sequel to long-term tracheostomy use, causing important morbidity including difficult to vocalization and control of air secretions, recurrent pulmonary infections, and cosmetic and social problems. Herein, we reported a new method for closure of persistent tracheocutaneous fistula with rib cartilages. Compared to other techniques previously reported, the variations of our strategy were the use of temporary metal-covered tracheal stent and the hinged turnover skin bi-flaps reinforced with rib cartilage grafts. Rib cartilages were useful in order to reconstruct the trachea and prevent stenosis. Since it become difficult to obtain the maintenance of the trachea stability until healing of suture was well established, a covered metallic stent was also inserted to avoid flap collapse. The stent was removed 3 months later. Six months follow-up showed normal tracheal patency.

Closure of a tracheocutaneous fistula by two hinged turnover skin flaps and a muscle flap: A case report

INTRODUCTION

Tracheocutaneous fistula is a complication of tracheostomy. Tracheocutaneous fistulectomy followed by primary closure carries a high possibility of complications.

PRESENTATION OF CASE

An 11-year-old boy underwent surgery to repair a tracheocutaneous fistula, using skin and muscle flaps. A vertical incision was made around the fistula and 3 skin flaps were prepared: 2 hinge flaps, and 1 to cover the skin defect (advanced flap). The 2 hinged turnover flaps were invaginated by multiple layered sutures, and a strap muscle flap was placed over the resulting tracheal closure. An advanced skin flap was used to cover the area of the previous defect. The patient was extubated immediately after surgery. He was discharged on the sixth postoperative day without tracheal leakage or subcutaneous emphysema. The patient is currently doing well, with no respiratory symptoms and no recurrence at the postoperative 5 months.

DISCUSSION

Our technique is minimally invasive and has a low risk of lumen stenosis, other complications, or recurrence.

CONCLUSION

This technique demonstrates the multiple-layered closure of a tracheocutaneous fistula, using skin flaps and a muscle flap.

A novel technique for closing a tracheocutaneous fistula using a hinged skin flap

We present the case of a 73-year-old man with successful closure of a persistent tracheocutaneous tissue defect that resulted from poor wound healing after a temporary tracheostomy was performed during treatment for drug-induced anaphylactic shock. We repaired the tracheal defect using a cutaneous flap with its cutaneous surface positioned to cover the tracheal lumen. The advantage of our method is that it minimizes the suturing required and results in fewer problems with anastomotic insufficiency. This is a simple, rapid method for treating tracheocutaneous fistulas.

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.

Vakuumassistierte Therapie zur Wundbehandlung im Kopf-Hals-Bereich

Chronic wounds are characterized by slow or nonexistent wound healing. Usually their treatment is expensive. Therefore new concepts in management are of interest in order to reduce treatment time and costs. One option is vacuum sealing. The concept of topical negative pressure is not new, and many chronic nonhealing wounds could be closed successfully with the help of vacuum sealing. Until now, there has been no documented case of vacuum sealing in head and neck reconstructive surgery. Our case shows the effectiveness of a vacuum-assisted device in successful closure of a chronic nonhealing wound in this region.

Plastische Deckung von Weichteildefekten im Gesicht

The difficulties in facial reconstruction derive from the unique character of the face and the availability of local matching tissues. Facial reconstructive surgery must aim at a functionally and aesthetically rehabilitated patient. The performance of facial plastic surgery requires an understanding and the application of many important principles. The aim of this paper is to review the critical factors to be considered in the management of surgical wounds by second-intention healing, primary closure, skin grafting, and repair with local or distant free flaps. The key concepts useful in flap choice and implementation are discussed. In addition, an overview of new developments in tissue engineering and gene therapy as they relate to facial plastic surgery is provided.