Pharyngocutaneous fistula (PCF) remains the most common and challenging complication following total laryngectomy (TL), occurring in 17%–34% of patients despite advances in surgical technique and perioperative care. PCF significantly increases morbidity, prolongs hospitalization by an average of 2–3 weeks, delays adjuvant therapy, and substantially increases healthcare costs. The pathogenesis of PCF is multifactorial, involving patient-related factors (comorbidities including hypothyroidism, nutritional status, and smoking), disease-related factors (tumor extent, previous radiotherapy, disease-free interval, and extralaryngeal spread), and surgical factors (closure technique and use of vascularized tissue). Recent systematic reviews and meta-analyses have identified several modifiable risk factors, including preoperative anemia (hemoglobin < 12.5 g/dL), hypoalbuminemia, hypothyroidism, and active smoking. Prevention strategies encompass three critical phases: preoperative optimization of nutritional status, correction of anemia and thyroid dysfunction, and pulmonary prehabilitation through incentive spirometry; intraoperative meticulous surgical technique with appropriate pharyngeal closure methods and selective use of vascularized tissue reconstruction; and postoperative monitoring with early fistula detection protocols, anti-reflux measures, structured respiratory physiotherapy, and antiemetic and laxative regimens. Salvage TL following chemoradiotherapy carries particularly high PCF rates (20%–35%), necessitating prophylactic reconstruction with pedicled or free flaps. Evidence demonstrates that pectoralis major myofascial flaps reduce PCF rates by approximately 22% in salvage cases, while horizontal pharyngeal closure decreases fistula incidence compared to T-shaped closure. Evidence for routine salivary bypass tube use is insufficient, and selective placement based on individualized risk assessment is recommended. This narrative review synthesizes current evidence on PCF prevention with Oxford Centre for Evidence-Based Medicine level of evidence grading, examining risk stratification systems, preoperative patient optimization protocols, surgical techniques, reconstructive strategies, and postoperative management approaches to reduce PCF incidence and improve outcomes for patients undergoing TL.
Rehabilitation of the atrophic maxilla presents a significant clinical challenge due to severe alveolar bone resorption, poor bone quality, and anatomical limitations such as sinus pneumatization. While traditional bone grafting procedures are effective, they are often invasive and unsuitable for medically compromised patients. This narrative review evaluates current implant-based treatment modalities, with a focus on graftless techniques including short, tilted, pterygoid, zygomatic, and patient-specific subperiosteal implants. A comprehensive literature search was conducted across multiple databases (PubMed, Google Scholar, EBSCO, Web of Science, and Cochrane Library) for studies published between January 1998 and December 2024. A total of 40 relevant articles were selected, highlighting that graftless solutions demonstrate high survival rates and reduced morbidity. Reported survival rates include up to 96% for short implants, 98.6% for tilted implants, approximately 97% for zygomatic implants, and 91% for pterygoid implants. Implants in sinus-augmented areas show variable success, with rough-surfaced implants outperforming machined ones. Key biomechanical considerations, such as implant diameter, splinting, and angulation, significantly influence load distribution and implant longevity. Overall, advancements in digital planning, implant technology, and biomaterials have established graftless implant approaches as effective and predictable alternatives for restoring function and esthetics in patients with atrophic maxillae, while minimizing surgical invasiveness.
