Q: Dr. Eppley, I have a tracheostomy hole that is refusing to close. It have been over a year, and no ENT doctor or surgeon wants totry becaus they are afraid it will fail an dlave a larger hol.e. There is significant very har scar tissue or cartilidge on each sideto fhte helo, and nobody around here can figure a way to graft it back together and then suture the soft tisssue (which is very tight. the hole is less than the diameter than a dime, its just the tissue is tight and the soft tissue is so tight. Do you think you can help? And how?
A: You have a well-epithelized tracheostomy scar/hole that is not going to heal or close over at this point. That is evident by the time that has passed after the tracheostomy tube removal but by the epithelium that now lines it. It may have gotten a smidge smaller due to surrounding wound contracture but this is now a healed permanent opening. Your surgeons are correct in that any attempts at trying to free up the surrounding tissues will not only not work but injuring the tissues runs the real risk of making it even bigger. (although the real risk is just one of wasting time and creating the need for more tissue healing since it has no chance of being successful)
Understanding how to successfully fix your tracheostomy hole (way beyond just a depressed scar) starts with understanding the true nature of the problem….there is a lack of tissue. The hole needs more tissue and the surrounding tissues are both scarred and are tissues of poor quality. They can not be relied upon to be the sole donor tissue for the closure. New tissues must be brought in to create one of the needed three layers. This is likely going to require a pedicled muscle flap from sternocleidomastoid muscle of the neck. (partial pedicled muscle flap) to serve as the vascularized interpositional tissue layer. This would be placed between the internal lining (created by turning in the current skin lining of the hole and either a small skin graft or local skin flap rotated over it.
Anything short of a solid three layer closure for your established tracheostomy closure is doomed to fail.
Dr. Barry Eppley