Vascularized rib for facial reconstruction

The reconstruction of maxillectomy defects is a complex problem encountered in plastic surgery. Defects can range in size and complexity from small defects requiring only soft tissue to complete maxillectomies requiring large tissue bulk, bone, and one or more skin paddles. The most difficult defects involve the skull base and orbit. The reconstructive surgeon is faced with the challenge of isolating the nasopharynx from the dura and globe while simultaneously restoring the bony framework of the maxilla and orbit to support the soft tissue of the cheek. The authors present a series of six reconstructions using a rectus abdominis muscle flap with associated vascularized rib for reconstruction of complex maxillectomy defects. This flap provides large soft-tissue bulk as well as bony support and a long vascular pedicle. A skin island can be taken with the flap, and the donor-site morbidity is comparable to that seen with a vertical rectus abdominis myocutaneous flap. Six flaps were used in five patients over a 20-month period. All patients had stable support of the orbit at follow-up with adequate soft-tissue coverage, and there were no incidences of visual changes.     

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.     

A reverse ulnar hypothenar flap for finger reconstruction

A reverse-flow island flap from the hypothenar eminence of the hand was applied in 11 patients to treat palmar skin defects, amputation injuries, or flexion contractures of the little finger. There were three female and eight male patients, and their ages at the time of surgery averaged 46 years. A 3 x 1.5 to 5 X 2 cm fasciocutaneous flap from the ulnar aspect of the hypothenar eminence, which was located over the abductor digiti minimi muscle, was designed and transferred in a retrograde fashion to cover the skin and soft-tissue defects of the little finger. The flap was based on the ulnar palmar digital artery of the little finger and in three patients was sensated by the dorsal branch of the ulnar nerve or by branches of the ulnar palmar digital nerve of the little finger. Follow-up periods averaged 42 months. The postoperative course was uneventful for all patients, and all of the flaps survived without complications. The donor site was closed primarily in all cases, and no patient complained of significant donor-site problems. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer, as indicated by 5 mm of moving two-point discrimination. A reverse island flap from the hypothenar eminence is easily elevated, contains durable fasciocutaneous structures, and has a good color and texture match to the finger pulp. This flap is a good alternative for reconstruction of palmar skin and soft-tissue defects of the little finger.     

Neuromucosal prelaminated flaps for reconstruction of intraoral lining defects after radical tumor resection

To reconstruct intraoral lining defects after radical tumor resection by reinnervated vascularized mucosa, eight distal radial forearm flaps and two fibula flaps were prelaminated. Prelamination was performed by exposing the vascularized fascia, onto which the split distal end of a sural graft was fixed. The fascia and the sural nerve graft were covered by device-meshed mucosa or small full-thickness mucosa pieces. These structures again were covered by a Silastic sheet as large as the future flap, and the wound was closed by the elevated skin and subcutaneous tissue. Coverage by a Silastic sheet enabled mucosal spreading on the fascia, and the final flaps were thin, mucus-producing, and larger than the originally inserted mucosa. The 10 neuromucosal prelaminated flaps were harvested together with the inserted sural nerve graft after 8 to 10 weeks. During this time, the patient underwent radiotherapy and chemotherapy. Donor sites were closed directly by the preserved skin and subcutaneous tissue. Intraoral defects were reconstructed successfully by eight neuromucosal prelaminated distal radial forearm flaps and two neuromucosal prelaminated fibula flaps. The sural nerve grafts, inserted between the fascia and the mucosa, were coaptated eight times with the lingual nerve and two times with the inferior alveolar nerve. Intended reinnervation of the mucosa could already be proved clinically and histologically in the first two patients after 11 and 9 months. Preservation of skin and subcutaneous tissue considerably lowered donor-site morbidity. Neuromucosal prelamination enables reconstruction of intraoral lining defects by reinnervated mucus-producing tissue. Reconstruction of other mucosa-lined structures by this method seems feasible. Avoidance of skin islands for reconstruction lowers donor-site morbidity.     

Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap

Multiple attempts to repair the Achilles tendon can be associated with major soft-tissue defects of skin and tendon necessitating reconstruction with free flaps. In view of its specific anatomical characteristics, the fasciocutaneous infragluteal free flap is best suited for restoring sensibility and achieving nearly full function, including resumption of sporting activities, with minimum donor-site morbidity. The anatomy, dissection technique, and results of 100 percent successful skin and tendon defect reconstruction in seven patients are presented.     

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Management of bone loss that occurs after severe trauma of open lower extremity fractures continues to challenge reconstructive surgeons. Sixty-one patients who had 62 traumatic open lower extremity fractures and combined bone and composite soft-tissue defects were treated with the following protocol: extensive debridement of necrotic tissues, eradication of infection, and vascularization of osteocutaneous tissue for one-stage bone and soft-tissue coverage reconstruction. The mechanism of injury included 49 motorcycle accidents (80.3 percent), five falls (8.2 percent), three crush injuries (4.9 percent), two pedestrian-automobile accidents (3.3 percent), and two motor vehicle accidents (3.3 percent). The bone defects were located in the tibia in 49 patients (79 percent; one patient had bilateral open tibial fractures), in the femur in seven patients (11.3 percent), in the calcaneus bone in four patients (6.5 percent), and in the metatarsal bones in two patients (3.2 percent). The size of soft-tissue defects ranged from 5 x 9 cm to 30 x 17 cm. The average length of the preoperative bony defect was 11.7 cm. The average duration from injury to one-stage reconstruction was 27.1 days, and the average number of previous extensive debridement procedures was 3.4. Fifty patients had vascularized fibula osteoseptocutaneous flaps, six had vascularized iliac osteocutaneous flaps, and five patients had seven combined vascularized rib transfers with serratus anterior muscle and/or latissimus dorsi muscle transfers. One patient received a second combined rib flap because the first combined rib flap failed. The rate of complete flap survival was 88.9 percent (56 of 63 flaps). Two combined vascularized rib transfers with serratus anterior muscle and latissimus dorsi muscle flaps were lost totally (3.2 percent) because of arterial thrombosis and deep infection, respectively. Partial skin flap losses were encountered in the five fibula osteoseptocutaneous flaps (7.9 percent). Postoperative infection for this one-stage reconstruction was 7.9 percent. Excluding the failed flap and the infected/amputated limb, the primary bony union rate after successful free vascularized bone grafting was 88.5 percent (54 of 61 transfers). The average primary union time was 6.9 months. The overall union rate was 96.7 percent (59 of 61 transfers). The average time to overall union was 8.5 months after surgery. Seven transferred vascularized bones had stress fractures, for a rate of 11.5 percent. Donor-site problems were noted in six fibular flaps, in two iliac flaps, and in one rib flap. The fibular donor-site problems were foot drop in one patient, superficial peroneal nerve palsy in one patient, contracture of the flexor hallucis longus muscle in two patients, and skin necrosis after split-thickness skin grafting in two patients. The iliac flap donor-site problems were temporary flank pain in one patient and lateral thigh numbness in the other. One rib flap transfer patient had pleural fibrosis. Transfer of the appropriate combination of vascularized bone and soft-tissue flap with a one-stage procedure provides complex lower extremity defects with successful functional results that are almost equal to the previously reported microsurgical staged procedures and conventional techniques.     

Perforator flaps from the lateral lower leg for intraoral reconstruction

Perforator flaps are based on cutaneous, small-diameter vessels that originate from a main pedicle and perforate fascia or muscle to reach the skin. Although these flaps have recently become popular for soft-tissue reconstructions in nearly all regions of the body, the systematic application of perforator flaps with short, small-caliber pedicles for intraoral reconstruction has not been reported. Experience with the use of 10 consecutive perforator flaps from the lateral lower leg for intraoral defect coverage is reported. In 10 cases, a 4- to 6-cm-long septocutaneous or myocutaneous perforating vessel from the peroneal artery, with a diameter of 1 to 2 mm, could be identified in the proximal one-half of the lateral lower leg. The thin, pliable skin paddles, measuring up to 6 x 8 cm, were used for defect coverage after resection of squamous cell carcinomas of the floor of the mouth (five cases), soft palate (one case), tongue (two cases), or buccal mucosa (two cases). Anastomoses were performed to the lingual artery and concomitant vein. Except for one case, all perforator flaps healed without complications and the functional results were satisfying. At the donor site, which was always closed directly, an approximately 15-cm-long scar resulted, without functional impairments. The peroneal artery was regularly preserved. Perforator flaps from the lateral lower leg might have many applications for intraoral soft-tissue reconstruction, especially because of their minimal donor-site morbidity.     

The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction

The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients' ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.     

Versatility and reliability of combined flaps of the subscapular system

One-stage reconstructions of complex or unusually large defects frequently require composite tissue transfers. The various components of these "chimeric" flaps facilitate three-dimensional reconstructions or the coverage of large surface defects. Data from 36 combined flaps from the subscapular arterial system are demonstrated in this series. Defect locations were evenly distributed between the upper and lower extremities. Eighty-three percent were two-component flaps, and 17 percent contained three or more various tissue components. Overall flap survival was 97 percent. Major complications included vascular revisions in four patients and seven secondary skin transplantations. Five cases contained osseous components. The independent mobility of skin, muscle, and bone proved to be a major advantage in the reconstruction of compound defects. Donor-site morbidity was acceptable; the most frequent donor-site complication was persistent seroma in 9 of 36 patients (25 percent). Patient satisfaction was high. Ninety-one percent were satisfied with the operative result and would undergo the operation again. Eighty-six percent accepted the aesthetic appearance of the donor site. The data demonstrate that these complex flap procedures are extremely reliable and versatile, thus avoiding multiple reconstructive procedures and achieving excellent reconstructive results with acceptable donor-site morbidity.     

Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity

The radial forearm flap is commonly used for reconstruction of tongue defects following tumor extirpation. This flap is easy to harvest and offers thin tissue with large-caliber vessels. However, its use leaves behind a conspicuous aesthetic deformity in the forearm and requires the sacrifice of a major artery of that limb, the radial artery. The anterolateral thigh cutaneous flap has found clinical applications in the reconstruction of soft-tissue defects requiring thin tissue. More recently, in a thinned form, the anterolateral thigh flap has been used for reconstructing defects of the tongue with functional results equivalent to that of the radial forearm flap. For the reconstruction of tongue defects, these two flaps could provide similar soft-tissue coverage, but they seem to result in different donor-site appearances. The donor site is closed primarily, leaving only a linear scar that is inconspicuous with normal clothing, and no functional deficit is left behind in the thigh. Thus, for the supply of flaps for tongue defects, a comparison between the radial forearm flap and the anterolateral thigh flap donor sites is provided in this study. Between December of 2000 and August of 2002, 41 patients who underwent reconstruction of defects of the tongue using either a radial forearm flap or an anterolateral thigh flap were evaluated. The focus was on the evaluation of the functional and aesthetic outcome of the donor site after harvesting these flaps for the purpose of reconstructing either total or partial tongue defects. Finally, a comparison was performed between the donor sites of the two flaps. The disadvantages of the radial forearm flap include the conspicuous unattractive scar in the forearm region, pain, numbness, and the sacrifice of a major artery of the limb. In some patients, the donor-site scar of the forearm acted as a social stigma, preventing these patients from leading a normal life. In contrast, the anterolateral thigh cutaneous flap, after thinning, achieved the same results in reconstructing defects of the tongue without the associated donor-site morbidity. Most importantly, the donor site in the thigh could be closed primarily in almost all patients without any functional deficit. The thinned anterolateral thigh cutaneous flap is a viable substitute for the radial forearm flap when reconstructing defects of the tongue. The results achieved are similar to those of the radial forearm flap, and the donor-site morbidity is significantly decreased.     

Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

Mandibular reconstruction with vascularized iliac crest: a 10-year experience

Since 1978, 35 patients have undergone mandibular reconstruction with vascularized iliac crest. During this time, the technique of raising and shaping the iliac crest has undergone a series of modifications. Initially, osteocutaneous segments based first on the superficial circumflex iliac system and later on the deep circumflex iliac system were used. More recently, only the inner table of the ilium has been employed, and where intraoral lining is required, an ulnar forearm free flap has been added. Thirty-two patients were reconstructed successfully. Of the three anastomotic failures, one bony segment was able to survive as a free graft. There were no donor-site complications. With continued experience, operative morbidity has been minimized, while the technique has been modified to tailor the reconstruction to the specific requirements of the patient. It is concluded that vascularized iliac crest provides the most appropriate mandibular reconstruction for a range of congenital and acquired defects.     

Reconstruction of composite through-and-through mandibular defects with a double-skin paddle fibular osteocutaneous flap

Microsurgical reconstruction of composite through-and-through defects of the oral cavity involving mucosa, bone, and external skin has often required two free flaps or double-skin paddle scapular or radial forearm flaps for successful functional and aesthetic outcomes. A safe, reliable technique using a double-skin paddle fibular osteocutaneous flap to restore the intraoral lining, mandibular bone, and external skin is described. A large elliptical or rectangular skin paddle is designed 90 degrees to the longitudinal axis of the fibula, over the junction of the middle and distal thirds of the lower leg, based only on the posterolateral septocutaneous perforators. This skin flap can be draped anteriorly and posteriorly over the fibular bone to reconstruct both the intraoral defect and the external skin defect. The area between the two skin islands of the intraoral flap and the external flap is deepithelialized and left as a dermal bridge between the two skin islands, as opposed to the creation of two separate vertical skin paddles, each based on a septocutaneous perforator. The transverse dimension of the flap can be as great as 14 cm, extending to within 1 to 2 cm of the tibial crest anteriorly and as far as the midline posteriorly, and with a length of up to 26 cm, this flap should be more than sufficient for reconstruction of most through-and-through defects. This technique has allowed the successful reconstruction of large composite defects, with missing intraoral lining, mandibular bone, and external skin, for 16 patients, with 100 percent survival of both skin islands in all cases and without the development of any orocutaneous fistulae.     

Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand

A vascularized bone segment of the ulna together with a posterior interosseous fasciocutaneous flap is harvested, including a cuff of the extensor pollicis longus muscle. The authors treated five male patients with metacarpal bone and soft-tissue defects of the hand using a distally based island osteocutaneous posterior interosseous flap. Their ages at the time of surgery ranged from 15 to 37 years (mean, 24 years). The bone defects were in the first metacarpal in three cases, the fourth metacarpal in one, and the fifth metacarpal in one. The length of the donated ulna ranged from 3 to 7 cm (mean, 5 cm). The follow-up period ranged from 5 to 92 months (mean, 39 months). All flaps survived completely. The posterior interosseous flap provides thin skin of good texture, together with vascularized bone, for a one-stage reconstruction of the metacarpal bone and soft-tissue defects in the hand.     

An alternative method to minimize pain in the split-thickness skin graft donor site

In the art of plastic surgery, the reconstruction of tissue defects to obtain cosmetic and functional recovery is the major concern. Skin grafting is the most frequently used procedure for reconstructing defects of various size and anatomical localizations. On the other hand, donor-site problems associated with this invaluable procedure are inevitable. Various methods are used in the postoperative management of the partial-thickness donor site created during the harvest of a split-thickness skin graft. Each technique has the potential for complications of fluid loss, excessive pain, prolonged period of healing and immobilization, hypertrophic scarring, and undesirable pigmentation. Donor-site pain is probably the most disturbing complication in the early postoperative period. The aim of this article is to point out the significance of donor-site pain, which has not been emphasized thoroughly in the literature, and to introduce flap skin as a potential graft donor site for patients in whom reduction of donor-site morbidity is of primary concern. The principal goal of the technique described in this article is to eliminate donor-site pain by harvesting the graft from the flap that is insensate after the elevation. In 15 patients, the overlying skin of the flap that had been used for reconstructive purposes was used as the donor site (group I). In the remaining 23 patients, the posterolateral thigh was used as the donor site (group II). Donor-site discomfort was recorded during the first 8 days postoperatively using a visual analogue scale. To analyze the data, we used the Friedman test, Dunn's multiple comparison test, and Mann-Whitney U test. It was observed that the visual analogue scale of both of the groups showed a significant decrease within days (group I, p < 0.0001; group II, p < 0.0001). The mean pain scores were significantly lower in group I than in group II (p < 0.0001). When donor-site pain is of primary concern, this procedure provides uneventful and comfortable healing while avoiding postoperative pain in the donor site. For that reason, this technique might be used in appropriate cases to minimize donor-site pain.     

Forefoot reconstruction by reversed island flaps in diabetic patients

Soft-tissue coverage of the foot is often difficult, especially when the distal third of the foot (dorsal or plantar aspects) is involved. The clinical situation can be further complicated when diabetic patients are affected by painful and unstable wounds of this kind because of the familiar phenomenon of vasculopathy. The purpose of this study was to evaluate the possibility of using distally based foot flaps to cover forefoot defects in diabetic patients. Preoperative selection of patients was the key to this study; those who had other major disease, chronic infection, bone involvement, and/or insufficient foot vascularization were excluded from the study. The authors report a series of 12 diabetic patients in whom the reconstruction of medium-sized defects (ranging from 1.5 x 2.0 cm to 3.0 x 7.0 cm) of the forefoot was performed using distally based dorsalis pedis flaps or medial plantar flaps. The transferred flaps survived and adapted well to the defects, except for one flap in a patient who had a slight venous insufficiency at outset. Wearing their own footwear, patients could walk after 20 to 30 days. After the follow-up period (3 months to 3 years), no skin breakdown in the treated areas was observed. Temporary donor-site pain was reported by medial plantar flap patients, and partial skin graft loss at the donor site occurred in some of the dorsalis pedis patients. The authors suggest that in selected cases, medium-sized soft-tissue defects involving the dorsal aspects or the weight-bearing areas of the diabetic foot can be successfully covered with distally based island flaps.     

Mandibular reconstruction in the radiated patient: the role of osteocutaneous free tissue transfers

This paper discusses our experience with the second metatarsal and iliac crest osteocutaneous transfers for mandibular reconstruction. The prime indication for this type of reconstruction was for anterior mandibular defects when the patient had been previously resected. Midbody to midbody defects were reconstructed with the metatarsal and larger defects with the iliac crest. In most cases, an osteotomy was done to create a mental angle. The evaluation of speech, oral continence, and swallowing revealed good results in all patients unless lip or tongue resection compromised function. Facial contour was excellent in metatarsal reconstructions. The iliac crest cutaneous flap provided a generous supply of skin for both intraoral reconstruction and external skin coverage but tended to be bulky, particularly when used in the submental area. Thirty three of 36 flaps survived completely. Flap losses were due to anastomosis thrombosis (1), pedicle compression (1), and pedicle destruction during exploration for suspected carotid blowout (1). Ninety three percent of bone junctions developed a solid bony union despite the mandible having had a full therapeutic dose of preoperative radiation. Despite wound infections in 8 patients, and intraoral dehiscence with bone exposure in 12 patients, all but one of these transfers went on to good bony union without infection in the bone graft.     

Tendofascial island flap based on distal perforators of the radial artery: anatomical and clinical approach

The possibility of transferring vascularized tissue to restore function and to resurface large defects, together with the use of composite flaps, has led to recent advances in "one-stage" reconstructive surgical procedures. On the basis of a previous study of the blood supply of the adipofascial flap and a new study of the blood supply of the flexor carpi radialis tendon from the transfascial and direct branches of the radial artery, a fascial island flap complete with tendon was devised and used to treat four male patients who had sustained traumatic soft-tissue losses on the dorsum of the hand and segmental losses of the extensor digitorum communis. The use of a completely vascularized, single-stage, composite flap did not involve sacrifice of the radial artery, the functional and aesthetic results were good, and there was minimal donor-site morbidity.     

Anterolateral thigh flap donor-site complications and morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.     

Repair of pharyngocutaneous fistulas with the submental artery island flap

Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, debridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 x 3 cm and the minimum size was 4 x 2 cm (average, 4.8 x 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donor-site morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed.