PMC8011658_01
Pharayngocutaneous fistula defect and IMAP flap raised on left 2nd intercostal perforator. Clinical photographs demonstrating (A) circumferential full thickness pharyngeal defect post scar and stricture release, followed by (B) left sided IMAP flap raised and islanded on a second intercostal perforator (Delta) which is shown with further magnification in (C).
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F1
IMAP flap was preferred rather than free tissue transfer for reconstruction. Intraoperative exploration demonstrated a suitable IMA/V perforator in the left 2nd intercostal space, which was utilized to raise an IMAP flap (Figure 1).
IMAP tube design. Clinical photographs demonstrating the process of IMAP tubing, de-epithelialization and inset. (A) The medial extension of the flap is de-epithelialized and the lateral portion is tubed with the epithelial surface forming the internal tube lining. This is diagrammatically represented with the measurements of the flap design used in this case in (B). (C,D) The flap was then rotated superiorly and a wide subcutaneous tunnel created, insetting the tubed IMAP proximally to the pharynx (previous tubed ALT flap) and distally to the esophagus.
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F2
After de-epithelialization and islanding, the flap was tunneled across a short skin bridge, inset into the defect over a nasogastric tube and the external defect was closed (Figure 2).
Post-operative Images and swallow at 6 weeks. (A) Depicts a post-operative swallow study demonstrating a patent pharyngeal tube with flow of contrast into the esophagus. (B) Post-operative clinical photograph demonstrating a well healed wound and donor site with no evidence of persisting pharyngocutaneous fistula.
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F3
Six- months post-operatively, he continues to maintain adequate dietary intake independent of his percutaneous endoscopic gastrostomy (PEG) tube, a significant improvement noted by both the patient and ongoing speech pathology assessments (Figure 3).