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Prevention of pharyngocutaneous fistula in salvage total laryngectomy: role of the pectoralis major flap and peri-operative management

  • P Sittitrai (a1), C Srivanitchapoom (a2) and D Reunmakkaew (a1)

This study aimed to evaluate the impact of an onlay pectoralis major flap in reducing the incidence of pharyngocutaneous fistula after salvage total laryngectomy and determine the complications of pectoralis major flap reconstruction.


A retrospective study was conducted of consecutive patients who underwent salvage total laryngectomy between 1995 and 2016. The pharyngeal defects were primarily closed with or without the pectoralis major flap.


Of 64 patients, 34 had primary pharyngeal closure alone (control group) and 30 received an onlay pectoralis major flap (pectoralis major flap group). The overall fistula rate was 15.6 per cent, with 17.6 per cent occurring in the control group and 13.3 per cent in the pectoralis major flap group (p = 0.74). The incidence rates of voice failure (p = 0.02) and shoulder disability (p < 0.001) were significantly higher in the pectoralis major flap group.


The pectoralis major flap in salvage total laryngectomy did not decrease the pharyngocutaneous fistula rate, and the incidence of flap-related complications was high. Appropriate surgical technique and post-operative care may reduce the incidence of pharyngocutaneous fistula.

Corresponding author
Address for correspondence: Dr Pichit Sittitrai, Department of Otolaryngology, Chiang Mai University Hospital, Chiang Mai, Thailand, 50200 Fax: +66 053 935564 E-mail:
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1 Sayles, M, Grant, DG. Preventing pharyngo-cutaneous fistula in total laryngectomy: a systematic review and meta-analysis. Laryngoscope 2014;124:1150–63
2 Gendreau-Lefèvre, AK, Audet, N, Maltais, S, Thuot, F. Prophylactic pectoralis major muscle flap in prevention of pharyngocutaneous fistula in total laryngectomy after radiotherapy. Head Neck 2015;37:1233–8
3 Patel, UA, Moore, BA, Wax, M, Rosenthal, E, Sweeny, L, Militsakh, ON et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg 2013;139:1156–62
4 Sharma, S, Chaukar, DA, Laskar, SG, Kapre, N, Deshmukh, A, Pai, P et al. Role of the pectoralis major myofascial flap in preventing pharyngocutaneous fistula following salvage laryngectomy. J Laryngol Otol 2016;130:860–4
5 Gil, Z, Gupta, A, Kummer, B, Cordeiro, PG, Kraus, DH, Shah, JP et al. The role of pectoralis major muscle flap in salvage total laryngectomy. Arch Otolaryngol Head Neck Surg 2009;135:1019–23
6 Guimarães, AV, Aires, FT, Dedivitis, RA, Kulcsar, MA, Ramos, DM, Cernea, CR et al. Efficacy of pectoralis major muscle flap for pharyngocutaneous fistula prevention in salvage total laryngectomy: a systematic review. Head Neck 2016;38(suppl 1):E2317–21
7 Hasan, Z, Dwivedi, RC, Gunaratne, DA, Virk, SA, Palme, CE, Riffat, F. Systematic review and meta-analysis of the complications of salvage total laryngectomy. Eur J Surg Oncol 2017;43:4251
8 Dedivitis, RA, Aires, FT, Cernea, CR, Brandão, LG. Pharyngocutaneous fistula after total laryngectomy: systematic review of risk factors. Head Neck 2015;37:1691–7
9 Liang, JW, Li, ZD, Li, SC, Fang, FQ, Zhao, YJ, Li, YG. Pharyngocutaneous fistula after total laryngectomy: a systematic review and meta-analysis of risk factors. Auris Nasus Larynx 2015;42:353–9
10 Paleri, V, Drinnan, M, van den Brekel, MW, Hinni, ML, Bradley, PJ, Wolf, GT et al. Vascularized tissue to reduce fistula following salvage total laryngectomy: a systematic review. Laryngoscope 2014;124:1848–53
11 Righini, C, Lequeux, T, Cuisnier, O, Morel, N, Reyt, E. The pectoralis myofascial flap in pharyngolaryngeal surgery after radiotherapy. Eur Arch Otorhinolaryngol 2005;262:357–61
12 Cömert, E, Tunçel, Ü, Torun, MT, Kiliç, C, Cengiz, AB, Sencan, Z et al. Pectoralis major myofascial flap in salvage laryngectomy. J Laryngol Otol 2014;128:714–19
13 Patel, UA, Keni, SP. Pectoralis myofascial flap during salvage laryngectomy prevents pharyngocutaneous fistula. Otolaryngol Head Neck Surg 2009;141:190–5
14 Oosthuizen, JC, Leonard, DS, Kinsella, JB. The role of pectoralis major myofascial flap in salvage laryngectomy: a single surgeon experience. Acta Otolaryngol 2012;132:1002–5
15 Sakai, A, Okami, K, Sugimoto, R, Ebisumoto, K, Yamamoto, H, Maki, D et al. Prevention of wound complications in salvage pharyngolaryngectomy by the use of well-vascularized flaps. Acta Otolaryngol 2012;132:778–82
16 Sousa, AA, Castro, SM, Porcaro-Salles, JM, Soares, JM, de Moraes, GM, Carvalho, JR et al. The usefulness of a pectoralis major myocutaneous flap in preventing salivary fistulae after salvage total laryngectomy. Braz J Otorhinolaryngol 2012;78:103–7
17 Sayles, M, Koonce, SL, Harrison, L, Beasley, N, McRae, AR, Grant, DG. Pharyngo-cutaneous fistula complicating laryngectomy in the chemoradiotherapy organ-preservation epoch. Eur Arch Otorhinolaryngol 2014;271:1765–9
18 Gilbert, MR, Sturm, JJ, Gooding, WE, Johnson, JT, Kim, S. Pectoralis major myofascial onlay and myocutaneous flaps and pharyngocutaneous fistula in salvage laryngectomy. Laryngoscope 2014;124:2680–6
19 Rothmeier, N, Bergmann, C, Mattheis, S, Weller, P, Lang, S. The primary use of pectoralis myofascial flap in salvage laryngectomy [in German]. Laryngorhinootologie 2015;94:232–8
20 Rappaport, WD, Hunter, GC, Allen, R, Lick, S, Halldorsson, A, Chvapil, T et al. Effect of electrocautery on wound healing in midline laparotomy incisions. Am J Surg 1990;160:618–20
21 Kumagai, SG, Rosales, RF, Hunter, GC, Rappaport, WD, Witzke, DB, Chvapil, TA et al. Effects of electrocautery on midline laparotomy wound infection. Am J Surg 1991;162:620–2;discussion 622–3
22 Ruidiaz, ME, Messmer, D, Atmodjo, DY, Vose, JG, Huang, EJ, Kummel, AC et al. Comparative healing of human cutaneous surgical incisions created by the PEAK PlasmaBlade, conventional electrosurgery, and a standard scalpel. Plast Reconstr Surg 2011;128:104–11
23 Moukarbel, RV, Doyle, PC, Yoo, JH, Franklin, JH, Day, AM, Fung, K. Voice-related quality of life (V-RQOL) outcomes in laryngectomees. Head Neck 2011;33:31–6
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  • EISSN: 1748-5460
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