Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap

Abstract

Tracheocutaneous fistula and tracheostomy scar are complications associated with the prolonged use of tracheostomy tubes. They have functional and cosmetic problems owing to tracheal tugging during swallowing and easily visible scars. Although many procedures exist to correct this issue, there is no consensus on the optimal surgical technique. Therefore, an ideal surgical procedure was devised. The study was performed on 12 patients between September 2016 and May 2021. All patients had persistent tracheocutaneous fistulas or hypertrophic scars on the neck after tracheostomy. All procedures were performed using a hinged flap and two myocutaneous local flaps. All patients had no complications, and their aesthetics were excellent in postoperative photographs. The scar was better on the straight scar when the flap's skin is denuded than on the VY advancement flap. It should be noted, however, that this procedure can cause the flap to become congested in a short period after head and neck surgery. This procedure is safe, reliable and simple for surgical closure. This was found to produce excellent cosmetic results with no major complications.

1. INTRODUCTION

Tracheostomies are frequently performed during the treatment of critically ill patients in intensive care and the operation of patients with head and neck cancers, such as thyroid cancer, and in paediatric patients with tracheomalacia. Persistent tracheocutaneous fistula or tracheostomy scar results from the failure of spontaneous closure after temporary tracheostomy decannulation. It has been recognised that 3.3% to 29% of all decannulated patients develop tracheocutaneous fistulas, although they are often seen in tracheomalacia. The presence of a tracheocutaneous fistula puts patients at a higher risk of developing other complications, such as pneumothorax, bronchitis and chronic aspiration, which may lead to pneumonia. ¹ , ² Patients with tracheocutaneous fistulas are more susceptible to excessive tracheal secretions, dysphagia, phonatory difficulties, ineffective coughing and local skin irritation. A persistent tracheocutaneous fistula may have a direct impact on the patient's social life, limiting daily activities, such as swimming and bathing. Tracheocutaneous fistulas also impose significant psychosocial issues owing to poor cosmesis. ³ When decannulated, patients heal by secondary intention; there is often atrophy and adhesion of the tracheal wall subcutaneous tissues, leading to depressed tracheal scars. Many studies have been conducted on the treatment of tracheocutaneous fistula or tracheostomy scar, but they are reported to cause many complications. ⁴ Surgical procedures that are aesthetically pleasing and prevent vertical traction of the cervical skin and recurrence of fistulas must be established. Therefore, we devised and reported a new surgical procedure.

2. METHOD

2.1. Study design

The study was performed on 12 patients between September 2016 and May 2021. All the patients had persistent tracheocutaneous fistulas or hypertrophic neck scars (Table 1). These patients had been referred to our department from a different department at the same institution because they desperately wanted their fistulas and scars to be removed. If the fistula remained, tracheal stenosis was confirmed by laryngoscopy to ensure that there was no problem with respiratory status after closure. All procedures were performed using a hinge flap and two local platysma V‐Y advancement flaps. All the patients agreed to undergo this procedure and provided written informed consent.

TABLE 1.

Characteristic and complication of patients.

Age	M/F	Disease	TCF	Period since last surgery	Complication	Scar
16	M	Cerebellar haemorrhage (7 years old)	−	9 years	None	Straight
21	F	Infective endocarditis	+	1 year	None	Straight
19	M	Thyroid cancer	+	8 year	None	Straight
41	F	Thyroid cancer	+	8 month	Flap congestion spontaneous healed	V‐Y
37	F	Thyroid cancer	+	4 month	Flap congestion spontaneous healed	V‐Y
52	F	Right buccal mucosa cancer	−	1 year 8 month	None	V‐Y(one side)
58	F	Tongue cancer	−	2 year 2 month	None	V‐Y
47	F	Left parotid gland cancer	−	1 year 8 month	None	V‐Y
50	F	Thyroid cancer	−	1 year	None	V‐Y
35	F	Thyroid cancer	+	6 month	None	Straight
5	F	Pierre Robin syndrome tracheomalacia	+	4 year 3 month	None	Straight
50	F	Basedow disease	−	9 month	None	Straight

Abbreviations: F, female; M, man; TCF, tracheocutaneous fistula; V‐Y, VY advancement flap.

2.2. Surgical technique

We designed an elongated spindle shape along the neck crease line. A hinge flap was created to separate the skin from the trachea by dropping the fistula wall and scarring into the tracheal side (Figure 1). We covered the tracheal closure with two V‐Y advancement myocutaneous flaps, including a platysma, from both lateral sides of the scar (Figure 2). If there was a fistula, it was covered with the tips of the two overlapping myocutaneous flaps. If there was no fistula, only the epidermis of the scar was denuded and the scar was dropped under the skin and covered with the flaps. When we denude the epidermis and detach the surrounding tissue, the scar tissue naturally falls into the tracheal side. If the neck skin tension is not strong enough, the flap skin is denuded and placed under the skin on the head and tail sides, and the scar will then be straight. The wound is closed by four layers: hinge flap skin, two myocutaneous flaps including plastyma and skin of the neck. As postoperative care, a film dressing is applied to the wound widely after surgery to inhibit the movement of the surrounding skin. In addition, gauze is placed over the wound as a pressure fixation. The patient is also asked to hold the wound with his/her own hand when coughing. To evaluate the surgical results, photographs and complications were assessed. Clinical data were collected through a chart review.

FIGURE 1.

Schema of hinge flap for tracheobronchial fistula. The grey area indicates where the hinge flap closes.

FIGURE 2.

Schema with V‐Y advancement flap after tracheal fistula closure or tracheostomy scar resection. The red line is the incision to move the V‐Y advancement flap. The skin of the flap may be denuded and placed under the skin.

3. RESULTS

Of the 12 cases in the study, all patients consulted other departments for tracheocutaneous fistula and neck scars, which were treated surgically in our department (Table 1). Six (50%) patients had tracheocutaneous fistula and six (50%) had only hypertrophic neck scars after tracheostomy. The ages of the patients ranged from 5 to 58 years.

All patients had no complications (Table 1), and two cases of V‐Y advancement flap scarring within a year after head and neck surgery showed postoperative flap congestion but healed without any surgical procedure. If there was no strong tension in the wound and it was easily suturable, we denuded the flap and made the wound straight in six cases.

The aesthetic results were excellent in postoperative photographs taken 6 months after surgery. The scar was better on the straight scar (six cases, 50%) (Figure 3) than on the V‐Y advancement skin muscle flap(6 cases, 50%) (Figure 4).

FIGURE 3.

Photographs of straight scars after this procedure in two cases (about 6 months later). (A, D) the flap design for subcutaneous soft tissue replacement in two pieces. (B, E) The scar was excised and the flap skin was denuded. (C, F) Straight scar had a good cosmetic appearance.

FIGURE 4.

Photograph of V‐Y advancement flap scar after this procedure (about 6 months later). (A) Design of V‐Y advancement flap after closing with hinge flap. (B): After elevation of V‐Y advancement flap. (C): Congested V‐Y advancement flap. (D): The V‐Y advancement flap healed without necrosis; however, the vertical scar was slightly hypertrophic.

4. DISCUSSION

With this technique, the tracheocutaneous fistula was closed without complications, and the tracheostomy scar healed cosmetically. There is no consensus regarding the surgical procedure for tracheocutaneous fistulas and tracheostomy scars. Serious surgical complications can cause subcutaneous emphysema, pneumothorax and pneumomediastinum after tracheocutaneous fistula repair. ³ , ⁵ , ⁶ The tracheal tug and hypertrophic scar of the neck must be repaired in a tracheostomy scar case. ⁷ Many repair methods have been described, including closure by secondary intention, primary closure, layered primary closure, local tissue and muscle flaps, tissue rearrangement which is discussed later and free flaps. ⁸ These methods are often associated with complications. In this study, we devised a new surgical treatment that is less complicated and cosmetically pleasing. The advantage of this method is that the hinge flap separates the trachea from the skin, thereby improving the sensation of tracheal tugging. The peritracheal area was not dissected and the flap covered the area directly above the tracheal closure to prevent dead space and subcutaneous emphysema. As a postoperative complication, the strength of this closure could be disrupted by a sudden elevation in airway pressure, such as that accompanied by paroxysmal coughing. Therefore, closure in four layers, two platysma muscle flap layers, and two skin flap layers was carried out to reinforce the fistula closure. ⁹ , ¹⁰ Therefore, subcutaneous emphysema did not develop in our patient. Additionally, as the wound is horizontal, the same as the collar line, the scar is cleaned. There was no tissue waste such as excess skin or dog ears.

Goldsmith et al and Hernot et al reported the use of a Z‐plasty and a rhomboid flap, respectively, for local flap closure, but these methods have the disadvantage of causing longitudinal scar. ¹¹ , ¹² Justin et al reported tracheocutaneous fistula closure with a turnover flap and Polydioxanone Plate. ¹³ However, we are not comfortable inserting an artificial device into an inflamed area. However, this approach has several drawbacks. In the case of the V‐Y advancement flap, the scar was visible as a double line. A case of closure with a combination of a hinge flap and a local flap, similar to our case, has been reported by Azuma et al However, the purpose of this method is different from that of our technique because it is performed to ensure closure of the large fistula and avoid postoperative pharyngeal stenosis. ¹⁴ After head and neck surgery, if the time since the initial surgery is short and the scar is immature, the flap may become congested. Congestion was observed in patients in less than 1 year after surgery. Therefore, we recommend that the procedure be performed after 1 year, postoperatively. This is because the inflammation around the tracheodermal fistula has decreased and the tracheal foramen scar is likely to have become a mature scar. In our cases, the scar was better on the straight scar than on the V‐Y advancement skin muscle flap. Therefore, in cases of low tension in the direction of the neck skin extension, it is better to denude the platysma myocutaneous flap epidermis and straighten the suture line. In our method, a hinge flap and a two‐layer myocutaneous flap were placed in front of the trachea. This allowed adequate resistance to airway pressure and did not cause subcutaneous emphysema, subsequent wound infection or re‐fistula. Additionally, although not fully evaluated, there was less skin tugging during swallowing using this surgical technique. This may be because a sufficient amount of soft tissue was emphasised between the skin and the trachea. It should be noted that very large defects cannot be accommodated and that the maximum defect and scar are 2 cm × 2 cm for this procedure. The optimal size of the flap is the maximum vertical diameter of the tracheostomy or tracheotomy scar is the width of the V‐Y advancement flap, and the length is two to three times that. Thus, the length of the flap should be 4–6 cm. As more patients recover from their therapy for malignant disease due to improved medical technology, we may anticipate a growing number of candidates for surgical closure of tracheocutaneous fistula and surgical repair of tracheostomy scar. ¹⁵ In summary, our technique is suitable for patients with a desire to improve cosmetic appearance, small fistulas or scars, and years since the head and neck surgery. This study has some limitations, such as its retrospective design, small sample size and selection bias when it came to choice of surgical strategy chosen for the individual patient. Further prospective studies or studies with larger sample sizes are necessary to draw firm conclusions about the optimal surgical repair of tracheocutaneous fistula and tracheostomy scars.

5. CONCLUSION

A safe, reliable and simple technique for surgical closure of a tracheocutaneous fistula and revision of the tracheostomy scar was presented. This procedure produced excellent cosmetic results with no complications.

FUNDING INFORMATION

This research received no specific grants from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare that there is no conflict of interest.

Shimada K, Komiya T, Ito N, et al. Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap. Int Wound J. 2023;20(7):2499‐2504. doi: 10.1111/iwj.14110

DATA AVAILABILITY STATEMENT

Research data are not shared