Massive pharyngocutaneous fistulae: salvage with two-layer flap closure

Massive pharyngocutaneous fistulae may be arbitrarily defined as those involving two-thirds or more of the circumference of the pharyngeal wall. Three such patients are presented, all after failed radiotherapy and surgery. The principles of management consist of salivary diversion, complete debridement, nutritional support, prophylactic antibiotics, and two-layer, well-vascularized overlapping closure. We currently recommend a radial forearm flap used in conjunction with a pectoralis muscle (or musculocutaneous) flap for rapid rehabilitation of these patients, particularly in the presence of obesity or an irradiated bed.