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The best results are obtained when it is possible to make the stoma in the inferior skin flap, using a separate fenestra in the skin (figures right), at a distance of close to one centimeter to the skin incision. This may be round, but in our experience, the most effective shape is semi-circular, with the same size and orientation as these of the trachea. The anterior (intact cartilaginous) portion of the trachea is sutured to the circular part of the fenestra, and the posterior (membranous) portion of the trachea is sutured to the straight/horizontal part, which runs parallel to the incision of the inferior skin flap. The sutures should be placed meticulously and ensure that there is skin cover over the bare edge of the trachea, so that no cartilage is exposed (figure right). Exposed cartilage may lead to perichondritis, infection, granulations and eventually stenosis.

In the same way, the postoperative use of a cannula, button or tracheostomy tube is to be avoided, if possible, since they cause friction to the mucocutaneous anastomosis, with the same end-result. In our experience in the Netherlands Cancer Institute it appears to be possible to have most patients leave the operating room without a cannula. A temporary cannula is only used if there is excessive edema of the skin flaps, causing obstruction, or excessive secretions, where a tube may aid in decreasing trauma to the tracheal mucosa caused by suction catheters. Once a stoma has started to form fibrous tissue, as in the case of tracheal stenosis, it is extremely difficult to arrest the process, and such a patient may be condemned to the use of a stoma button for all or much of the time. A typical example of a stoma created in this way with a Provox voice prosthesis in situ is shown in the figure to the right.




As already mentioned earlier, an additional improvement of the stoma can be obtained by cutting the sternal head of the sternocleidomastoid muscles (figure). This causes no functional deficits, but results in a flatter peristomal area, which facilitates the use of external stoma appliances such as an HME and/or an automatic tracheostoma valve. After wound healing is completed and possibly checked with a barium swallow (approximately 10 days postoperatively), the patient can start with vocal rehabilitation under the guidance of the speech therapist.