Extended palatal island mucoperiosteal flap

The extended palatal island mucoperiosteal flap was used in 53 cases over a ten-year period. Its many uses include reconstruction of the soft palate and resurfacing of retromolar and cheek defects. Its reliability with a success rate of 96% and spontaneous epithelialization of the donor site at three months makes it an attractive method of reconstruction.     

The palatal island mucoperiosteal flap for primary intraoral reconstruction following tumor ablative surgery

Reconstruction of intraoral mucosal defects following tumor ablative surgery can be a challenging problem. The objective of this study was to evaluate the use of the palatal island mucoperiosteal flap (PIMPF) in reconstructing intraoral defects resulting from ablative tumor resections. The study included eight consecutive patients who underwent primary reconstruction using the PIMPF following intraoral tumor resections in a 5-year period by a single surgeon at a tertiary referral institute. Patients included five men and three women ranging in age from 32 to 69 years. Four patients were smokers (averaging 40 pack-years). None had received prior irradiation therapy. Resultant surgical defects ranged in size from 6 to 16.5 cm² (mean 12.3 ± 3.9) and included areas of soft/hard palate, lateral pharyngeal wall, retromolar trigone and inner cheek. Final pathological findings revealed three benign and five malignant tumors, mostly from minor salivary gland origin. All patients began oral diet between postoperative days 1 and 4 (mean 2 days). All flaps survived well with good postoperative wound healing except one minor flap dehiscence that eventually healed by granulation tissue with no further surgery needed. All donor sites were completely healed by remucosalization within 5–13 weeks. No patients manifested permanent velopharyngeal insufficiency, speech impairment, or airway compromise after a follow-up period ranging from 13 to 56 months (mean 31.3 ± 15.9). The PIMPF was found to be an attractive single-staged versatile and reliable reconstructive option for postero-lateral oral cavity/oropharyngeal defects that provides well-vascularized, sensate mucosa with minimal morbidity.     

Palatal reconstruction with the palatal island flap

OBJECTIVES/HYPOTHESIS: The management of palatal defects resulting from the extirpation of benign and malignant lesions uses a variety of methods, with the optimal techniques allowing maximal postoperative function with minimal morbidity. The palatal island flap is an effective, reliable technique for reconstructing postablative oral cavity defects. METHODS: All patients who underwent palatal resections for benign or malignant lesions at a tertiary care, referral-based head and neck cancer center since 1995 were eligible. Ten patients were identified whose surgical defects were reconstructed with palatal island flaps. The cases were reviewed for the symptomatology, tumor features, defect size, perioperative and postoperative management, complications, and impact on palatal function. RESULTS: Ten patients ranging in age from 18 to 81 years underwent palatal island mucoperiosteal flaps after resection of a variety of benign and malignant tumors, most arising from minor salivary glands. The defects ranged in size from 5 to 15 cm2, with extension into the floor of the nose in four cases and to the skull base in two. Nine patients were discharged on a regimen of oral diet, and no patient manifested permanent velopharyngeal insufficiency, speech impairment, or airway compromise. Follow-up ranged from 3 months to 6 years, with an average follow-up of 18.5 months. Delayed donor site re-epithelialization required debridement in one case, and two patients required obturation of small oronasal fistulae. CONCLUSION: The palatal island mucoperiosteal flap provides an effective means of reconstructing hard and soft palate defects with few complications and low morbidity.     

The facial artery-buccinator musculo-mucosal flap for reconstruction of the palate

Since may 1999, 5 facial artery musculo-mucosal (FAMM) flaps have been used for mucosal reconstruction of the top of the mouth. The FAMM flap, first described by Pribaz in 1993 is a modification of the naso-labial cutaneous flap. The flap can be inferiorly based on the facial vessels (orthograde flow) or superiorly based (retrograde flow). It can easily reconstruct palate, alveolus and soft palate defects. The are of rotation has its pivot point inferiorly at the retromolar trigone, superiorly at the gingival labial sulcus. The FAMM flap has been used for 2 palatal fistula after facial blast injuries and 1 secondary cleft palate surgery. For the cleft palate surgery an Lefort 1 osteotomy with iliac crest graft was associated. All the flap but one survive with primary healing. One partial necrosis was noted but spontaneously healed secondarily. The FAMM flap is a reliable flap for mucosal reconstructions of the top of the mouth. The flap dissection is easy and the donor site morbidity is low.     

Palatal Flap Modifications Allow Pedicled Reconstruction of the Skull Base

Objectives: Defects after endoscopic expanded endonasal approaches (EEA) to the skull base, have exposed limitations of traditional reconstructive techniques. The ability to adequately reconstruct these defects has lagged behind the ability to approach/resect lesions at the skull base. The posteriorly pedicled nasoseptal flap is our primary reconstructive option; however, prior surgery or tumors can preclude its use. We focused on the branches of the internal maxillary artery, to develop novel pedicled flaps, to facilitate the reconstruction of defects encountered after skull base expanded endonasal approaches. Study Design: Feasibility. Methods: We reviewed radiology images with attention to the pterygopalatine fossa and the descending palatine vessels (DPV), which supply the palate. Using cadaver dissections, we investigated the feasibility of transposing the standard mucoperiosteal palatal flap into the nasal cavity and mobilizing the DPV for pedicled skull base reconstruction. Results: We transposed the palate mucoperiosteum into the nasal cavity through limited enlargement of a single greater palatine foramen. Our method preserves the integrity of the nasal floor mucosa, and mobilizes the DPV from the greater palatine foramen to their origin in the pterygopalatine fossa. Radiological measurements and cadevaric dissections suggest that the transposed, pedicled palatal flap (the Oliver pedicled palatal flap) could be used to reconstruct defects of the planum, sella, and clivus. Conclusions: Our novel modifications to the island palatal flap yield a large (12–18 cm²) mucoperiosteal flap based on a ～ 3 cm pedicle. The Oliver pedicled palatal flap shows potential for nasal cavity and skull base reconstruction (see video, available online only).     

Masseter muscle flaps and buccal mucosa transposition flaps in the reconstruction of the dorsal oral cavity and the oropharynx]

The m. masseter crossover flap according to Tiwari combined with a buccal mucosa transposition flap represents an excellent technique for a primary two-layered closure of defects due to surgical removal of T2- and small T3-tumors of the posterior part of the lateral floor of the mouth, the posterior edge of the tongue, the retromolar trigone, the soft palate and the tonsilar region. Especially advantageous are the low postoperative morbidity, the low rate of postoperative complications, and good functional and cosmetic results. The surgical expenditure is little and recommends the use of this technique also in patients with reduced operability.     

The use of palatal island flaps as an adjunct to microvascular free tissue transfer for reconstruction of complex oromandibular defects

OBJECTIVE: To determine the efficacy of using palatal island flaps in combination with free tissue transfer for reconstruction of large, complex oral cavity defects. STUDY DESIGN: Prospective evaluation of patients with large, combined defects of the oral cavity reconstructed with palatal flaps in conjunction with microvascular free tissue transfer. METHODS: Elevation of a palatal flap was performed after completion of tumor resection. The flap was rotated and secured into place. A free flap was then harvested and inset to reconstruct the remaining oromandibular defect. Free flaps included the rectus abdominis (6), fibula (16), and radial forearm (6). RESULTS: Large complex oral cavity defects were repaired with a palatal island flap in conjunction with microvascular free tissue transfer in 28 consecutive patients. There were no complications associated with this flap. CONCLUSION: Maximal functional rehabilitation of large, complex oral defects requires independent reconstruction of the various regions of the oral cavity rather than single flap reconstruction. When used as an adjunct to free tissue transfer, the palatal island flap offers a reliable method for reconstructing large combination defects.     

Functional outcomes following palatal reconstruction with a folded radial forearm free flap

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.     

The temporalis muscle flap for reconstruction after head and neck oncologic surgery.

OBJECTIVE: To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects. STUDY DESIGN: Fresh cadaver dissection and 5-year retrospective chart review. METHODS: A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base. RESULTS: Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing. CONCLUSIONS: Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.     

Combined intraoral and lateral temporal approach for palatal malignancies with temporalis muscle reconstruction

OBJECTIVE: To evaluate the use of a combined lateral temporal fossa and intraoral approach to resect palatal carcinomas and the use of a temporalis myofascial flap for reconstruction. DESIGN: Retrospective chart review of a case series. SETTING: Tertiary university referral hospital. PATIENTS: Sixteen patients underwent a combined approach for resection of palatal carcinoma; 5 of the 16 were edentulous. Six types of tumors were treated: adenoid cystic carcinoma (3 patients), low-grade mucoepidermoid carcinoma (5 patients), squamous cell carcinoma (3 patients), polymorphous low-grade adenocarcinoma (2 patients), osteosarcoma (1 patient), ameloblastoma (1 patient), and hyalinizing clear cell carcinoma (1 patient). MAIN OUTCOME MEASURES: The postoperative diet, velum competence, flap viability, complications, and survival. RESULTS: Fifteen (94%) of 16 patients were able to resume their preoperative diets. No velopharyngeal insufficiency was encountered. All flaps survived and none required repeated surgical intervention. Five patients developed serous otitis media and 2 patients required flap revision secondary to posterior choanal obstruction. One patient died of complications unrelated to the procedure. CONCLUSIONS: A combined intraoral and lateral temporal fossa approach allows for (1) en bloc resection of palatal malignancies along with resection of involved pterygoid muscles, (2) isolation and resection of descending palatine nerves and the proximal second division of the trigeminal nerve, and (3) primary reconstruction of the palatal defect by means of the temporalis muscle rotated into the operative defect. This method is especially useful in treating patients with perineural spread of palatal carcinoma, and in those who are edentulous.     

The uvulopalatal flap for reconstruction of the soft palate

OBJECTIVE: To determine the indications, complications, and outcomes of the uvulopalatal flap in the reconstruction of defects of the soft palate. STUDY DESIGN: Retrospective review. METHODS: Patient data were obtained from the hospital records of 18 patients who had soft palate defects reconstructed with the uvulopalatal flap over a 5-year period at a tertiary academic medical center. RESULTS: Eleven patients had the uvulopalatal flap as the sole method of reconstruction, whereas this flap was used in combination with a radial forearm free flap, pectoralis flap, and skin graft in 4, 2, and 1 patients, respectively. All flaps were successful in soft palate reconstruction. One flap was successfully revised after additional tumor resection. A partial flap dehiscence occurred in one patient and healed uneventfully. Speech and swallowing function was dependent on initial tumor stage and the scope of tumor resection. CONCLUSIONS: The uvulopalatal flap is a simple and effective method of soft palate reconstruction either alone or in combination with other methods of reconstruction for selected oropharyngeal defects.     

内镜下带血管蒂鼻中隔黏骨膜瓣修复颅底缺损

目的 探讨内镜下应用带血管蒂的鼻中隔黏骨膜瓣修复颅底硬膜缺损的方法及疗效.方法 回顾性分析2008年7月至2010年3月间收治的8例应用带血管蒂的鼻中隔黏骨膜瓣鼻内镜下修复术后颅底硬膜缺损及创伤性脑脊液鼻漏患者的临床资料及随访结果.8例患者均为男性,年龄28～60岁,平均年龄41岁.其中前颅底血管外皮瘤1例、嗅神经母细胞瘤1例(Kadish C型)、筛窦癌1例、鼻咽癌放疗后局部复发3例、颅底类癌1例、脑脊液鼻漏伴反复颅内感染1例.其中前颅底缺损6例,中颅底缺损2例.手术采用内镜经鼻入路,直视下获取以鼻后动脉为蒂的一侧鼻中隔黏骨膜瓣.组织瓣覆盖硬膜缺损后,周缘敷以明胶海绵,并用生物蛋白胶固定,鼻内以碘仿纱条、水囊及膨胀海绵支撑.术后5～7 d撤除全部鼻内支撑物.结果 1例鼻中隔瓣部分坏死,其余7例鼻中隔瓣全部成活.1例术后7 d有脑脊液鼻漏,再次手术探查以腹部脂肪封堵漏口成功,术后随访6～24个月,颅底组织愈合良好,无延迟性脑脊液漏及颅内感染发生.结论 内镜经鼻入路采用带血管蒂鼻中隔黏骨膜瓣修复颅底硬膜缺损是一种可靠的颅底重建方法.

Abstract：

Objective To introduce a method and the clinical effects of repairing skull base defects and dural defects using vascular pedicled nasoseptal mucoperiosteal flaps through an endoscopic endonasal approach. Methods The clinical and follow-up data for 8 patients who underwent endoscopic endonasal reconstruction of skull base defects and cerebrospinal fluid rhinorrhea with a vascular pedicled nasoseptal mucoperiosteal flap between July 2008 and March 2010 were retrospectively reviewed. All patients were male. The age of these patients ranged from 28 to 60 years (average 41 years). The diagnosis for these patients included one hemoangiopericytoma of the anterior skull base one olfactory neuroblastoma (type of Kadish C) , one ethmoid sinus cancer, three local recurrent cancers of the nasopharynx after radiotherapy,one carcinoid of skull base and one traumatic cerebrospinal fluid rhinorrhea with recurrent intracranial infection. There were six anterior skull base defects and two middle cranial fossa defects. An endoscopic endonasal surgical approach was used for the repair. A pedicled flap using the nasal septal mucoperiosteum based on the posterior nasal artery was harvested from the ipsilateral side. The tissue flap was used to cover the dural defects. The margin was covered with gelatin sponge and fixed with fibrin glue. The nasal cavity was packed with iodoform gauze, a Foley catheter balloon and Merocel in this sequence to secure the flap in place. Nasal packing was removed 5 to 7 days postoperatively. Results Partial septal flap necrosis was found in one case, but the flaps in the other 7 cases survived. A postoperative cerebrospinal fluid leak occurred in one case 7 days after surgery. This was re-explored and successfully repaired with abdominal fat.All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 6 to 24 months follow-up period. Conclusion The vascular pedicled nasoseptal mucoperiosteal flap is a reliable choice for endoscopic endonasal skull base reconstruction.     

Oropharyngeal reconstruction: current state of the art

Oropharyngeal reconstruction represents one of the greatest challenges in the surgical rehabilitation of patients with head and neck cancer. This article reviews several reconstruction methods, starting with the primary closure and healing by secondary intention all the way to the complex sensate microvascular flap reconstructions. Small defects such as tonsillar, small tongue base, and partial palatal defects may be closed primarily or left to granulate. This is assuming that there is no communication with the neck or bone exposure. Local flaps such as the palatal island, submental, and buccal mucosal flaps are used to close small to moderate-sized defects. Split-thickness skin grafts are also appropriate for small to moderate-sized defects. Larger defects such as total palatal, more than 50% of the tongue base, and composite tongue base/palatal/pharyngeal defects may be closed with regional myocutaneous pedicled flaps such as the pectoralis major, lower trapezius, or latissimus dorsi pedicled flaps. Microvascular tissue transfer is an excellent alternative for closure of moderate to large-sized defects. Free tissue transfer includes the radial forearm and the lateral arm free flaps. Both of these can have a sensory component. Free jejunal flaps are used for total or subtotal hypopharyngeal defects. Free gastro-omental flaps may be used for oropharyngeal and hypopharyngeal reconstruction as well. For defects involving bone, fibular flaps are an excellent option and can provide sensation. The scapular free flap may be used as well and offers the advantage of having two skin paddles (scapular and parascapular) for internal and external lining. Following a reconstructive ladder is extremely important in ensuring good function and, hence, improved quality of life.     

One-stage reconstruction following resection of oropharyngeal carcinoma]

Fifty-nine cases undergone one-stage reconstruction following radical resection for oropharyngeal carcinoma were reviewed. Pectoralis major myocutaneous flap has been our first choice for reconstruction of surgical defects. A composite repair with forehead island flap and mucosal flap of the posterior pharyngeal wall for defect of the total soft palate was recommended. Preoperative radiation had some influence on wound healing. The 3 and 5 year survival rates were 58.1% and 41.7% respectively, and the cosmetic and functional restorations were satisfactory in most patients operated.     

The tongue flap in palatal defect reconstruction

INTRODUCTION: A palatal defect with bucconasal fistula often follows exeresis of palatal tumors. It cannot be directly sutured. Several techniques have been used to cure such defects: palatal obturator, free, or local flaps. TECHNICAL NOTE: The tongue pediculated flap is an easy, safe, and reliable surgical option to reconstruct palatal defects. The tongue flap is a double-layer muscular and mucosal flap that requires two surgeries. During the first, the flap is harvested on the tongue and partially sutured on the anterior portion of the palatal defect. During the second, the pedicle is freed from the tongue and sutured to the posterior portion of the palatal defect. Between these two surgeries the patient is fed through a nasogastric tube. DISCUSSION: The tongue flap is easy and reproducible. It can be recommended in mediopalatal defects after cancer palatal surgery. Its esthetical and functional results are excellent. It is an alternative to palatal obturator, which are not well tolerated in the long run. Similar but uneven results are obtained with free flaps. Free flaps do not require a second surgery but are more difficult to implement in developing countries.     

折叠前臂桡侧游离皮瓣在上颌、腭部缺损修复中的应用

目的：探讨折叠前臂桡侧游离皮瓣修复上颌、腭部组织缺损的特点。方法: 应用折叠前臂皮瓣修复4例上颌、腭部恶性肿瘤切除后组织缺损。结果:4例前臂皮瓣修复全部成活,随访3～24个月,皮瓣与腭部黏膜伤口愈合良好,口鼻腔分隔良好,呼吸、语言和吞咽等口腔功能得以基本维护,面部和腭部外形较满意。结论:折叠前臂游离皮瓣是修复上颌、腭部组织缺损较好的材料之一。     

Oronasal fistula in sequels of labialalveolarvelopalatine clefts

Labial and palatine maxillary clefts are treated by surgery, as for oronasal fistula. One of the most important parts of management is the timing of primary surgery in order to avoid growth disturbance. The authors describe the various possibilities to close secondary oronasal fistula. The timing and choice of surgical techniques are still debated and being improved. Various surgical techniques are available, from mucoperiosteal palatal flap to a free flap. Nevertheless, the mucoperiosteal palatal flap is the most commonly used. In some cases mucoperiosteal flaps are impossible to perform, so other options for extreme cases are discussed.     

Use of the palatal flap for closure of an oronasal fistula

Palatal obturators are frequently used in the initial treatment of postoperative palatal fistulae to address the associated problems experienced with speech and swallowing. Many reconstructive surgical techniques for palatal defects have been reported. Although palatal-based flaps are less frequently reported, they can offer a relatively simple reconstructive option with minimal morbidity in patients with acquired palatal defects. We present a case report of a patient requiring reconstruction of a midline oronasal fistula after resection of a palatal malignancy and review the literature concerning this technique.     

Considerations for free-flap reconstruction of the hard palate.

OBJECTIVE: To evaluate the use of microvascular free-tissue transfers in the reconstruction of hard palate defects. DESIGN: Retrospective review of a case series. SETTING: Two tertiary referral centers. PATIENTS: Thirty patients had hard palatal defects that resulted from ablative oncologic surgery: 10 total or subtotal palatal defects, 14 hemipalatal defects, and 6 anterior arch defects. INTERVENTION: Nine fibular, 11 rectus abdominus, 3 scapular, 6 radial forearm, and 1 latissimus dorsi free flaps were used to reconstruct these defects. MAIN OUTCOME MEASURES: Separation of the oral cavity from the nasal and sinus cavities, complications, oral diet, speech intelligibility, and overall quality of life. RESULTS: No flap failures occurred, and all palatal defects were ultimately sealed. Nineteen patients eat a regular diet, while the remainder maintain a soft diet. Twelve patients use a conventional dental prosthesis; 8 of the dental prostheses are supported by implants. Of 23 patients examined for speech, 18 have no disorders, 3 exhibit hyponasal speech, and 2 have hypernasal speech. Overall University of Washington, Seattle, quality of life scores were fair in 2 patients, good in 6, and excellent in 12. CONCLUSIONS: Free-flap reconstruction of the palate provides reliable permanent separation of the oral and sinonasal cavities in one stage. In addition, the potential for dental rehabilitation with the restoration of masticatory function and normal phonation exists. Flap choice is tailored to specific palatal defects as well as patient needs.     

Vascularized bone graft is a better option for the reconstruction of maxillary defects

We read the article of Kinnunen et al., which evaluated the result of maxillary defects, and feel some objections. We present our considerations of their operative indication and thoughts based on our surgical experiences. Defects after palatectomy, which have left no dentition for the retention of an obturator, require vascularized bone-containing free flaps. Local flaps are available in only small defects of Class 1 and 2a. Most palatomaxillary defects following malignant tumor abrasion are classified as 2b, 2c, 3, or 4, which require microsurgical free flap transfer combined with bony reconstruction. Regarding bony reconstruction, non-vascularized bone grafts tend to be absorbed. Thus, we believe that bony reconstruction should be performed with vascularized bone. We agree with the authors’ comment that PTMF may be useful in repairing defects due to complications in microvascular procedures in the palatal area. However, even when bone segment is required for salvage surgery, using a vascularized bone flap is more preferable. A parietal bone-fascial-periosteal flap based on the superficial temporal vessels is a suitable and reliable bone flap for the reconstruction of a maxillary defect following free skin flap transfer to the palate.