|Year : 2018 | Volume
| Issue : 4 | Page : 169-173
Regional flaps in maxillofacial and oral soft-tissue reconstruction: Experiences and challenges in a developing country
Ramat Oyebunmi Braimah1, Abdurrazaq Olanrewaju Taiwo2, Aremu Adebayo Ibikunle1, Micah Olalekan Gbotolorun3, Mike Adeyemi3, Bala Mujtaba1
1 Usmanu Danfodiyo University Teaching Hospital, Department of Dental and Maxillofacial Surgery, College of Health Sciences, Sokoto, Nigeria
2 Usmanu Danfodiyo University/Usmanu Danfodiyo University Teaching Hospital, Department of Surgery/Dental and Maxillofacial Surgery, College of Health Sciences, Sokoto, Nigeria
3 University of Lagos, Department of Oral and Maxillofacial Surgery, College of Medicine, Lagos, Nigeria
|Date of Web Publication||24-Sep-2018|
Dr. Ramat Oyebunmi Braimah
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Maxillofacial and oral defects are complex to reconstruct because of the intricate nature of tissues. The aim of this study is to present our experience in maxillofacial and oral soft-tissue defects reconstruction using regional flaps. Patients and Methods: This is a retrospective study of maxillofacial and oral soft-tissue reconstruction (MFOSTR) in the Department of Dental and Maxillofacial Surgery of a University Teaching Hospital, northwest Nigeria, over a 4 years' period. Data such as age, sex, diagnosis, type of flap used, complications, and prognosis were collected and analyzed with IBM SPSS Statistics for Windows Version 20 (Armonk, NY, USA: IBM Corp). Results: A total of 64 MFOSTRs were performed during the study out of which 22 (34.4%) were done using regional flaps. They consist of 10 (45.5%) males and 12 (54.5%) females, with a male: female ratio of 0.8:1. Cancrum oris (17 [77.3%]) was the main indication for regional flap utilization in the MFOSTR. Deltopectoral flap (18 [81.8%]) was the most commonly used flap in our series. Other flaps used were; pectoralis major 3 (13.6%) and latissimus dorsi 1 (4.5%) flaps. Total flap failure was observed in 3 (13.6%). Conclusion: Despite personnel and infrastructure deficit in developing countries, especially sub-Saharan Africa, maxillofacial and oral reconstruction in our hospital has achieved some success. Patient selection is important for overall flap success.
Keywords: Deltopectoral, flaps, latissimus dorsi, maxillofacial, pectoralis major, regional
|How to cite this article:|
Braimah RO, Taiwo AO, Ibikunle AA, Gbotolorun MO, Adeyemi M, Mujtaba B. Regional flaps in maxillofacial and oral soft-tissue reconstruction: Experiences and challenges in a developing country. Turk J Plast Surg 2018;26:169-73
|How to cite this URL:|
Braimah RO, Taiwo AO, Ibikunle AA, Gbotolorun MO, Adeyemi M, Mujtaba B. Regional flaps in maxillofacial and oral soft-tissue reconstruction: Experiences and challenges in a developing country. Turk J Plast Surg [serial online] 2018 [cited 2019 May 20];26:169-73. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/4/169/242054
| Introduction|| |
Maxillofacial and oral soft-tissue reconstruction (MFOSTR) following ablative tumor resection in the head-and-neck region has undergone tremendous changes over the last 20 years. The main aim of reconstruction is to restore facial contour (esthetics) and function (mastication, deglutition, and speech). Reconstruction of jaw and mouth defects represents a challenge to the surgeon.,,,, These challenges are enormous in the developing countries, especially in sub-Saharan Africa. Most of the patients are not able to carry out extensive investigative procedures such as computed tomogram angiography and magnetic resonance imaging due to out of pocket health-care payment system. Those that could afford these investigations may have to travel long distances and take long appointments because of limited equipment and machines.
Local and regional flaps have been developed based on the better understanding of the physiology of skin perfusion. The understanding of the arterial supply has been a continuous process following the pioneering works of Saint-Cyr et al. Regional flaps are located at a significant distance from the recipient site and because of this reason; it usually has its own blood supply in the form of a named vessel. Flaps can be classified based on movement pattern, vasculature, and composite tissues. The most commonly utilized classification system for muscle flaps is that of Mathes and Nahai which is based on their vasculature.
To the best of our knowledge, no study has reported their experience in soft-tissue reconstruction using regional flaps in the maxillofacial and oral region in our center. Therefore, the main aim of the current study is to present our experience and challenges in MFOSTR using regional flaps in Sokoto, Northwest region of Nigeria.
| Patients and Methods|| |
This was a retrospective study of MFOSTR in the Department of Dental and Maxillofacial Surgery of a University Teaching Hospital, Sokoto, Northwest Nigeria, from 2014 to 2017. Case notes were retrieved, and data such as age, sex, diagnosis, type of flap used, complications, and prognosis were collected. The inclusion criteria are patients with MFOSTR using regional flaps with complete information, while the exclusion criteria are case notes with incomplete or missing records.
Data were stored and analyzed using IBM SPSS Statistics for Windows Version 20 (Armonk, NY, USA: IBM Corp). Results were presented as simple frequencies and descriptive statistics. Statistical significance was set at P < 0.05.
| Results|| |
A total of 64 MFOSTR were performed during the study with 22 (34.4%) using regional flaps. They consist of 10 (45.5%) males and 12 (54.5%) females, with a male: female ratio of 0.8:1 [Table 1]. Age ranged from 5 to 68 years with mean ± standard deviation [SD] (17.5 ± 19.6). Most of the patients were between the age group 1–10 years (15 [68.2%]) [Table 1]. Cancrum oris was the main indication for soft-tissue flap utilization in the maxillofacial region using regional flaps (17 [77.3%]), this was followed by squamous cell carcinoma in 3 (13.6%) cases. Other diagnoses are shown in [Table 2]. There was statistically significant difference when the age group of patients was compared with the diagnosis (χ2 = 66.000, df = 12, P = 0.000) as most of the diagnosis was observed in the age group of 1–10 years.
Deltopectoral flap (18 [81.8%]) was the most commonly used flaps in our series. Other flaps utilized in our series are as shown in [Table 3]. The most common complications associated with the flaps in our series were infection in 6 (27.3%) cases, while total flap failure was recorded in 3 (13.6%) cases [Table 3]. Other complications associated with each of the flaps were shown in [Table 3]. When types of flaps were compared with outcome, most of the outcomes were satisfactory in 17 (77.3%) cases, while 2 (9.1%) deaths were recorded [Table 3]. The follow-up period ranged from 0 to 12 months with mean ± SD (6.8 ± 3.9).
|Table 3: Distribution of types of flaps with associated complications and outcome|
Click here to view
| Discussion|| |
The maxillofacial and oral region has structures that are static and dynamic as well as special organs responsible for special functions such as mastication, deglutition, and speech. These special functions are important for good quality of life after treatment. In the principle of reconstructive surgery, what is removed should either be repaired or replaced. There are diverse types of regional flaps in the reconstruction of soft-tissue defects in the maxillofacial and oral region, and these include the following: deltopectoral, pectoralis major, latissimus dorsi, and radial forearm flaps., The site, size, and shape of the defect and the medical history determine the choice of these flaps. Other factors that determine the choice of these flaps include, but not limited to the following: age, sex, patient preference, skill of the surgeon, and availability of instruments and support staffs.
Although the aim of the reconstructive surgeon is to improve function and cosmetics; sometimes, this may be difficult to achieve in some patients with large defects. The cosmetic appearance, particularly the loss of facial skin and bone may also present reconstructive challenges.
Female preponderance was observed in our series in contrast to many studies that have reported a male predominance., In a study by Agbara et al., in the same region, as the current study gave the reason for this male preponderance as the indoor lifestyle of females in this environment due to their religious inclination. Female preponderance has been reported by Rao et al. in their study. The age range of patients in the current study was observed to be between 5 and 68 years. This sociodemographic observation was reported by Bartella et al. in a retrospective, observational study of 86 patients who had defects of the facial soft-tissue reconstructed after excision of malignant tumors.
We also observed in this present study that most of the patients fell in the age group of 1–10 years. This was so because most of the patients with soft-tissue defects in the maxillofacial region were secondary to cancrum oris. Cancrum oris, which is an infectious lesion, destroys the facial and oral tissues including the surrounding structures., This destruction leaves large tissue defects (soft and hard) requiring reconstruction. Agbara et al. have also reported similar age group preponderance in their study.
Deltopectoral flap (DP) was the most common flaps utilized in our series. Bakamjian was the first to describe the DP flap in 1965 as a head-and-neck reconstructive option, and since then, the flap has been named after him. The DP flap is a pedicled axial fasciocutaneous flap based on the internal mammary artery perforator arteries. The flap can be raised based on the angiosomes associated with the flap. Delaying a DP flap may improve flap survival, especially with extension of the flap beyond the deltopectoral groove. In our series, when the DP flap was raised beyond the deltopectoral groove, the residual defect beyond the grove was covered with a split-thickness skin graft [Figure 1], Black horizontal arrow]. This extension may be necessary when the defect is high up on the cheek as seen in cancrum oris patients [Figure 1], White horizontal arrow]. Delay of the flap is thought to the following: condition the tissue to ischemia, increase vascularity, sympathectomy, reactive hyperemia, stimulation of inflammatory cascade with release of vasodilators, vascular reorganization with opening up of choke vessels, increasing vessels in the subdermal plexus, and a more longitudinal reorganization of vessels. All our cases of DP flap in cancrum oris reconstruction had the flap delayed for 7 days and modified using split-thickness skin graft for inner lining of the oral defect. This modification is essential because NOMA defects were through and through defects with loss of skin, muscle, and mucosa resulting in orocutaneous fistula. Other ways of improving survival of DP flap is supercharging the flap by developing it pedicled to the pectoralis major flap. The DP flap was also used in a patient following squamous cell carcinoma of the buccal-and-cheek region resection, where it was combined with cervical flap [Figure 2]a and [Figure 2]b to close the defect.
|Figure 1: Deltopectoral flap in a cancrum oris patient showing flap (white horizontal arrow) and residual defect (black horizontal arrow)|
Click here to view
|Figure 2: (a) Outline of the deltopectoral flap in a squamous cell carcinoma patient (b) deltopectoral flap combined with cervical flap|
Click here to view
The pectoralis muscle flap was described by Ariyan in 1978 as “workhorse” for head-and-neck reconstruction. Since then, the flap had remained a valuable choice in head-and-neck reconstruction. The main arterial supply to the pectoralis muscle is the thoracoacromial artery which is a branch of the second portion of the axillary artery. The main advantage of this flap is that it can be used to reconstruct very large defects, and it is also very resistant to infection and effects of radiotherapy. The disadvantage of this flap is that its use is limited to its arch of rotation and in addition not very pliable because of its bulk. The pectoralis muscle flap was used in 3 (13.6%) patients with osteogenic sarcoma, rhabdomyosarcoma, and squamous cell carcinoma [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d.
|Figure 3: (a) Surgical defect for pectoralis major flap placement (b) raising of the pectoralis major muscle flap to expose the vessels (c) pectoralis major muscle flap tunneled above the clavicle (d) pectoralis major muscle flap sutured in place|
Click here to view
The latissimus dorsi myocutaneous flap is one of the most commonly used free flaps in microvascular reconstructive surgery. The first description of its use as a pedicled flap in head-and-neck reconstruction was by Quillen et al. in 1978. It is usually regarded as a bailout flap when other flaps have failed. This flap was utilized in one patient only with advanced osteogenic sarcoma of the mandible extending into the temporal region as a first-line flap [Figure 4]a,[Figure 4]b,[Figure 4]c.
|Figure 4: (a) Surgical defect for latissimus dorsal flap (b) latissimus dorsal flap in place (c) latissimus dorsal flap after flap division and suturing into position|
Click here to view
Total flap failure was observed in 3 (13.6%) of our patients as follows: 1 (4.5%) case of pectoralis major flap and 2 (9.0%) cases of the deltopectoral flap. In the pectoralis major patient, overwhelming infection due to the inability of the patient to procure antibiotics could have contributed. In addition, it was observed during raising of the flap that the pectoralis muscle fibers were very thin and friable probably due to chronic malnutrition as a result of the inability of the patient to eat properly for several months before presentation in the hospital. In the 2 (9.0%) cases of failed deltopectoral muscle flaps, the children with cancrum oris repair mistakenly pulled the flap apart while sleeping as their companions failed to restrain them. Flap infection was observed in 6 (27.3%) patients; however, this did not lead to total flap failure. In view of the fact that most of the patients were uneducated and keeping personal hygiene difficult might have been responsible for this high infection rate. We recommended that patients that cannot be motivated for proper personal hygiene despite being uneducated should not be a candidate for the regional flap. Two (9.0%) deaths were recorded in our series, 1 (4.5%) case from anesthetic complications during surgery while another one (4.5%) died as a result of renal shutdown from adjuvant chemotherapy.
| Conclusion|| |
Despite personnel and infrastructure deficit in developing societies, MFOSTR in our hospital has achieved some success. Distant or microvascular free flaps require more equipment and materials, therefore, was not utilized in any of our patients; however, we hope to commence this procedure in the nearest future. Good patient selection for the regional flap is essential in overall flap success.
The authors are grateful to the health records staffs for the assistance rendered during data retrieving and documentation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fernandes R. Local and Regional Flaps in Head and Neck Reconstruction: A Practical Approach. 1st
ed. Ames, Iowa, USA: John Wiley and Sons, Inc.; 2015.
Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000;22:17-26.
Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: A cochrane systematic review of randomised controlled clinical trials. Cochrane Database Syst Rev 2006;21:696-710.
Mehta RP, Deschler DG. Mandibular reconstruction in 2004: An analysis of different techniques. Curr Opin Otolaryngol Head Neck Surg 2004;12:288-93.
Mukerji R, Mukerji G, McGurk M. Mandibular fractures: Historical perspective. Br J Oral Maxillofac Surg 2006;44:222-8.
Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 2006;94:538-45.
Riman HB, Akpan ES. Healthcere financing and outcomes in Nigeria: A State level Study using Multivariate Analysis. Inter J of Human and Soc Sci 2012:2;296-309.
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.
Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: Experimental and clinical correlation. Plast Reconstr Surg 1981;67:177-87.
Yonehara Y, Nakatsuka T. Reconstruction of oral and maxillofacial soft tissue defects. Jpn J Oral Maxillofac Surg 2015;61:496-504.
Baliarsing AS, Thorat TS, Gupta A. Flap selection in head and neck cancer reconstruction. Int J Otorhinolaryngol Clin 2013;5:63-76.
Agbara R, Obiadazie AC, Fomete B, Omeje KU. Orofacial soft tissue reconstruction with locoregional flaps in a health resource-depleted environment: Experiences from Nigeria. Arch Plast Surg 2016;43:265-71.
Bartella AK, Ghassemi M, Hölzle F, Ghassemi A. Reconstruction of facial soft tissue: Comparison between conventional procedures and the facelift technique. Br J Oral Maxillofac Surg 2016;54:1006-11.
Rao J, Deora H. Surgical excision with forehead flap as single modality treatment for basal cell cancer of central face: Single institutional experience of 50 cases. J Skin Cancer 2014;2014:320792.
Braimah RO, Adeniyi SA, Taiwo AO, Ibikunle AA, Gbotolorun MO, Aregbesola SB, et al
. Risk factors and Mortality rate of acute cancrum oris (Noma) in Sokoto Northwest Nigeria: A 13 year survey. J Pediatr Dent 2017;5:1-5. [Full text]
Ibikunle AA, Adeniyi SA, Taiwo AO, Braimah RO, Gbotolorun OM, Soyele OO, et al
. Management of 159 cases of acute cancrum oris: Our experience at the Noma children hospital, Sokoto. Arch Med Health Sci 2017;5:172-6. [Full text]
Bakamjian VY. A Two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965;36:173-84.
Tsuchida Y, Tsuya A, Uchida M, Kamata S. The delay phenomenon in types of deltopectoral flap studied by xenon-133. Plast Reconstr Surg 1981;67:34-41.
Adeniyi SA, Taiwo AO, Ibikunle AA, Braimah RO, Gbotolorun OM, Ogbeide ME, et al
. Pattern of tissue destruction among patients diagnosed with cancrum oris (Noma) at a Northwestern Nigerian Hospital, Sokoto. Saudi J Oral Sci 2017;4:101-5. [Full text]
Nishi Y, Rikimaru H, Kiyokawa K, Watanabe K, Koga N, Sakamoto A, et al.
Development of the pectoral perforator flap and the deltopectoral perforator flap pedicled with the pectoralis major muscle flap. Ann Plast Surg 2013;71:365-71.
Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.
Quillen CG, Shearin JC Jr., Georgiade NG. Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area: Case report. Plast Reconstr Surg 1978;62:113-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]