|Year : 2021 | Volume
| Issue : 2 | Page : 83-86
Demographic properties and functional result analysis of patients with palatal defects reconstructed with microvascular tissue transfer
Anil Demiroz1, Tugba Feryal Yildiz2, Oguz Cetinkale1
1 Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Bakırköy Sadi Konuk Training and Research Hospital, Health Sciences University, Istanbul, Turkey
|Date of Submission||25-May-2020|
|Date of Acceptance||23-Aug-2020|
|Date of Web Publication||26-Mar-2021|
Dr. Anil Demiroz
Cerrahpaşa Tıp Fakültesi, Plastik Cerrahi Anabilim Dalı, 34098 Fatih, İstanbul
Source of Support: None, Conflict of Interest: None
Background: Palatal defects are still challenging for the reconstructive surgeon since the palate carries important functional roles in swallowing and articulating while providing an adequate airway. The aim of this article is to discuss the preferred free flap types for palatal reconstruction and present the functional outcome. Material and Methods: Records of patients who underwent microsurgical palatal reconstruction between 2012 and 2017 were reviewed for demographic properties, defect properties, flap of choice, and complication rates. A questionnaire was applied to the patients for assessment of speech, swallowing, regurgitation, snoring, and overall satisfaction. Results: Four patients were operated for palatal defects with a mean size of 23.25 cm2. The most commonly used free flap was the radial forearm flap in our four patient series. All patients reported improvement for every functional criterion in the questionnaire. Conclusion: Free flaps are an acceptable method for restoring palatal function. Radial forearm free flap was the flap of choice for reconstruction of large palatal defects in this retrospective review.
Keywords: Anterolateral thigh flap, microsurgery, palatal reconstruction, radial forearm free flap
|How to cite this article:|
Demiroz A, Yildiz TF, Cetinkale O. Demographic properties and functional result analysis of patients with palatal defects reconstructed with microvascular tissue transfer. Turk J Plast Surg 2021;29:83-6
|How to cite this URL:|
Demiroz A, Yildiz TF, Cetinkale O. Demographic properties and functional result analysis of patients with palatal defects reconstructed with microvascular tissue transfer. Turk J Plast Surg [serial online] 2021 [cited 2021 Apr 23];29:83-6. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/83/312187
| Introduction|| |
Palatal defects are still a challenge for the reconstructive surgeon. The palate plays important functional roles in swallowing and speech. The palate is a mechanical barrier in between the nasal and oral cavities. It acts like a valve to block the airflow to the nose, and it takes part in mastication, bolus propulsion, and phonation. Defects secondary to tumor resections are the most common cause of palatal defects following congenital clefts. The goals of palatal reconstruction include obtaining appropriate wound healing, separating the oral and nasal cavities, restoring palatal competence and function, restoring normal mastication and deglutition, and maintaining a patent airway. Local and regional flap options used in palatal reconstruction have variable reconstructive success rates., However, the overwhelming majority of the defects require more tissue than local and regional options can provide. Microvascular free tissue transfer has yielded excellent results in large defects for maintaining optimal volume, surface area, and function in single stage.
The aim of this study was to evaluate the reconstructive and functional restorative results of our patients who underwent the palatal repair with microvascular free tissue transfers.
| Material and Methods|| |
This study was approved by the local ethics committee and conducted in accordance with the Declaration of Helsinki. All patients that were included in the study were given and signed an informed consent form. Records of four patients who underwent free flap reconstruction from 2012 to 2017 for palatal defects were reviewed. Demographic properties, the primary reason and size of the palatal defect, the flap type, and complications were assessed. The size of the defect was measured in sagittal and coronal planes using a sterile ruler.
A questionnaire was prepared for the patients' self-assessment of functional outcomes. In this survey, the patients were asked to score their speech improvement, swallowing function in liquid and solid foods, regurgitation, snoring, and overall satisfaction in a scale from 1 to 10 where 10 corresponds to the highest point for agree.
| Case Reports|| |
A 31-year-old male had a Class II palatal defect of 25 cm2 according to Brown classification caused by a shotgun injury. A radial forearm flap of 6 cm × 6 cm was used for reconstruction of the defect. The vascular pedicle followed a subcutaneous tunnel and was anastomosed to the right-sided facial artery and vein. No complications were observed postoperatively. The functional result was assessed on postoperative 29th-month follow-up [Figure 1].
|Figure 1: (a and b) Patient 1; palatal defect of 25 cm2 size due to a shotgun wound 3 years ago was reconstructed with radial forearm free flap. Preoperative (a) and postoperative 28th day (b) appearances of the palate|
Click here to view
A 39-year-old female had a palatal defect of 4 cm × 4 cm due to adenoid cystic carcinoma resection 1 year ago. The palatal defect was Class I according to Brown classification and was reconstructed with a radial forearm flap with facial artery and vein used as recipient vessels. No postoperative complications were observed. The patient was recurrence free and metastasis free on postoperative 36th-month follow-up.
A 50-year-old male patient was admitted with an 8 cm × 5 cm Brown class II palatal defect secondary to adenoid cystic carcinoma resection. An anterolateral thigh flap of 9 cm × 6 cm was used for reconstruction. Facial artery and vein were used as the recipient vessels to be anastomosed to the pedicle that was positioned through a subcutaneous tunnel. Facial artery and vein were used as the recipient vessels to be anastomosed to the pedicle that was positioned through a subcutaneous tunnel. No complications occurred during the immediate postoperative period. Postoperatively on the 22nd month, a metastatic mass at the liver was detected, and it was treated with radiofrequency ablation. No local recurrences were observed at the primary tumor area.
A 40-year-old male patient had a 4 cm × 3 cm palatal defect following adenoid cystic carcinoma resection. The defect was class II according to Brown classification. Reconstruction was performed with a radial forearm flap in size of 5 cm × 4 cm. The facial artery was used as a recipient artery, whereas the lingual vein was the recipient vein of choice because of the small caliber of the facial vein. No complications were observed postoperatively [Figure 2]. The patient had no recurrences or metastasis in 9 months of follow-up.
|Figure 2: (a and b) Patient 4; 12 cm2 palatal defect due to adenoid cystic carcinoma resection 2 years ago was reconstructed with radial forearm free flap. Preoperative (a) and postoperative 20th day (b) appearances of the palate|
Click here to view
| Results|| |
Three of the patients were male and one was female. The mean age was 40 (31–50). The mean size of the palatal defect was 23.25 cm2 (12–40 cm2). Three patients had underwent the palatal resection for adenoid cystic carcinoma and one had wide palatal defect due to a shotgun wound. Radial forearm free flaps were used for two of the malignancy patients and one shotgun defect patient. The remaining patient who had undergone partial maxillectomy had a reconstruction with anterolateral thigh flap. There were no microsurgical/wound-related complications [Table 1]. The mean period of follow-up was 24 months (9–36 months). All patients reported improvement in solid food nutrition and speech according to questionnaire results.
All patients gave the highest points (mean = 10) for overall satisfaction with their operations, but their mean assessment point for speech improvement was 6, for swallowing function with liquids was 5.75, for swallowing function with solid meals was 6, for snoring was 5.75, and for bolus impulsion was 5 [Table 2].
| Discussion|| |
The palate is comprised of multiple structures constituting a 3-dimensional structure. Reconstructive goals focus on the restoration of both form and function. Current reconstructive techniques could provide integrity without restoration of coordinated dynamic muscular function, yet still achieve acceptable outcomes. Palatal obturators and autologous tissues are available for closure, and for autologous reconstruction, both surrounding and distant tissues are available.
Autologous reconstruction of large palatal defects involves a high risk of complications associated with a long anesthesia time, more complicated surgery, and a long hospitalization period. In the patients with a poor prognosis or poor general condition, leaving the defect for secondary healing after resection and rehabilitation with a palatal obturator can be a suitable option. The use of obturators has the advantage of shorter operative time and a significant reduction in the hospital stay. In addition, it provides a complete visualization of the cavity in case of tumor recurrence, expediting the oncological follow-up. However, it should be pointed out that functional outcome with the use of prosthetics depends on the amount of remaining tissue after the procedure.,, Swallowing dysfunction, unintelligible speech, nasal regurgitation, hygiene problems, and adaptation problems of the prosthesis are potential drawbacks, especially in patients with large defects or the ones requiring radiotherapy.
Reconstruction with local flaps is often considered for the defects occupying <50% of the palatal surface. Many methods are available for small palatal defects, especially for the ones located on the posterior palate. Pharyngeal flap, bilateral buccal flaps, buccinator flap, facial artery musculomucosal flap, palatal island flap, and buccal fat pad flap are commonly used local options for reconstructive purposes. The most distinctive advantage of these options is the transferred tissue's similarity in form and function. However, there are drawbacks of these procedures. Scar contracture may pull the remnants and flap tissue away from the pharyngeal walls and lead to velopharyngeal insufficiency. This type of reconstruction relies on adjacent tissue transfer, and it may leave the tissue under tension or cause cumbersome secondary defects on the donor area. If the treatment plan includes radiotherapy, these disadvantages become even more prominent.
Regional flaps such as the temporalis myofascial flap, the septal nasal flap, the submental island flap, and pectoralis flap are reasonable alternatives for the patients who have received the previous radiotherapy or who have a large lateral defect because of their bulkiness. Lack of tissue similarity, relatively increased risk of revision surgeries, and donor-site morbidities with possible additional defects are important disadvantages.
For both Type IIA and IIB palatal defects, a large surface area for transverse palatal defects with or without moderate volume loss is required. These types of defects may be a result of the resection of the lower five walls of the maxilla with the preservation of the orbital floor. Free tissue transfers are capable of providing a large surface area and the desired volume. Therefore, free flaps are the first-line reconstructive option when the defect size is >75% of the palatal surface area, especially if radiotherapy is anticipated. In order to improve the functional outcomes, some modifications have been reported. Brown et al. suggested using an additional superiorly based pharyngeal flap. McCombe et al. introduced a radial forearm flap folded over a palmaris longus tendon sling. Ross et al. evaluated the use of the anterolateral thigh flap for intraoral defects and the effects of primary thinning. Rieger et al. have introduced soft palate insufficiency repair procedure that included small incisions along the free edge of folded radial forearm flap for putting together subdermal and submucosal flaps from lateral and posterior pharyngeal walls.
The radial forearm flap has been a popular choice in palate reconstruction due to its pliability, pedicle length and consistency, thinness, and easy technique, making it the first-line treatment for large palatal defects. Nevertheless, the major concerns about this flap are major artery sacrification and significant donor site morbidity., The anterolateral thigh flap offers greater volume, but in those patients with thick adipose tissue, this advantage can become a handicap because of the risk of airway compromise. At our center, radial forearm free flap is the most preferred alternative in palatal reconstruction. We preferred the anterolateral thigh flap for reconstruction in one patient because more volume was required. A bone-containing free flap was not considered for any of the patients due to surgeon preference. Radial forearm flap was considered to be the easiest and fastest option because of its relatively long and reliable pedicle. Although a complementary stage of bone grafting for further dental restoration was possible, none of the patients requested further surgery.
In this study, we only aimed to demonstrate patients' satisfaction rate. Our results gave us an overview of the patients' improvement in the quality of life in the simplest way. For all the functional criteria questioned in our survey, all the patients reported satisfactory results. Although all patients scored less than the maximum in any of the functional criteria, it was interesting to see that all patients scored the maximum points for overall satisfaction. All the patients in the study had experienced eating and speaking with a palatal defect for a considerable period before their operations. We assume that this was the reason of overall satisfaction.
Because of the retrospective nature of the study, we were not able to use the previously validated palatal function scoring systems. Furthermore, some objective diagnostic tests such as barium swallowing test, endoscopic evaluation, magnetic resonance imaging, or videofluoroscopy would be helpful to evaluate the velopharyngeal function, but all the patients found taking these tests uneasy and refused further evaluation. Thus, the lack of functional assessment remained subjective as an important limitation of the study.
Another limitation of our study was the reduced sample size. Although it is difficult to describe an algorithm based on the experience of only four patients, the presentation of these cases can be helpful for future studies in this area.
| Conclusion|| |
The achievement of the reconstructive goals relies on a comprehensive understanding of the palate anatomy and function. The radial forearm free flap is the most commonly used free flap for palatal defects because of its advantageous features as thin nature, pliability, consistent pedicle, and easy dissection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
van der Sloot PG. Hard and soft palate reconstruction. Curr Opin Otolaryngol Head Neck Surg 2003;11:225-9.
Kostrubala JG. Repair of extensive palatal defects with skin tubes. Plast Reconstr Surg (1946) 1950;5:512-5.
Colmenero C, Martorell V, Colmenero B, Sierra I. Temporalis myofascial flap for maxillofacial reconstruction. J Oral Maxillofac Surg 1991;49:1067-73.
Shestak KC, Schusterman MA, Jones NF, Johnson JT. Immediate microvascular reconstruction of combined palatal and midfacial defects using soft tissue only. Microsurgery 1988;9:128-31.
Seikaly H, Rieger J, Zalmanowitz J, Tang JL, Alkahtani K, Ansari K, et al
. Functional soft palate reconstruction: A comprehensive surgical approach. Head Neck 2008;30:1615-23.
Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998;108:215-9.
Aramany MA, Myers EN. Surgical and prosthetic treatment of superficial carcinoma of the oral cavity. J Prosthet Dent 1985;54:820-3.
Wang CH, Huang IY, Du JK, Chen JH, Lee HE, Lee KW, et al
. Reconstruction of the soft palate in oral cancer to repair an operative defect with speech aid prosthesis: A case report. Kaohsiung J Med Sci 2007;23:536-40.
Jeong EC, Jung YH, Shin JY. Use of postoperative palatal obturator after total palatal reconstruction with radial forearm fasciocutaneous free flap. J Craniofac Surg 2015;26:e383-5.
Gillespie CA, Kenan PD, Ferguson BJ. Hard palate reconstruction in maxillectomy. Laryngoscope 1986;96:443-4.
Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg 1969;43:29-41.
Mann RJ, Fisher DM. Bilateral buccal flaps with double opposing Z-plasty for wider palatal clefts. Plast Reconstr Surg 1997;100:1139-43.
Kaplan EN. Soft palate repair by levator muscle reconstruction and a buccal mucosal flap. Plast Reconstr Surg 1975;56:129-36.
Pribaz J, Stephens W, Crespo L, Gifford G. A new intraoral flap: Facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992;90:421-9.
Millard DR Jr., Seider HA. The versatile palatal island flap: Its use in soft palate reconstruction and nasopharyngeal and choanal atresia. Br J Plast Surg 1977;30:300-5.
Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: Review of the literature and report of 15 cases. J Oral Maxillofac Surg 2000;58:158-63.
Hanasono MM, Utley DS, Goode RL. The temporalis muscle flap for reconstruction after head and neck oncologic surgery. Laryngoscope 2001;111:1719-25.
Rivera-Serrano CM, Lentz AK, Pinheiro-Neto C, Snyderman CH. Cadaveric study of the posterior pedicle nasoseptal flap: A novel flap for reconstruction of pharyngeal defects and velopharyngeal insufficiency. Plast Reconstr Surg 2013;132:1269-75.
Zhang DM, Chen WL, Lin ZY, Yang ZH. Use of a folded reverse facial-submental artery submental island flap to reconstruct soft palate defects following cancer ablation. J Craniomaxillofac Surg 2014;42:910-4.
Kiyokawa K, Tai Y, Inoue Y, Yanaga H, Yamauchi T, Mori K, et al
. Minimally invasive functional reconstruction after extended oropharyngeal resection including soft palate and base of tongue using a pectoralis major myocutaneous flap. Scand J Plast Reconstr Surg Hand Surg 2002;36:71-9.
Britt CJ, Hwang MS, Day AT, Boahene K, Byrne P, Haughey BH, et al
. A review of and algorithmic approach to soft palate reconstruction. JAMA Facial Plast Surg 2019;21:332-9.
McCarthy CM, Cordeiro PG. Microvascular reconstruction of oncologic defects of the midface. Plast Reconstr Surg 2010;126:1947-59.
Al Deek NF, Wei FC, Kao HK. Free tissue transfer to head and neck: Lessons learned from unfavorable results-experience per subsite. Clin Plast Surg 2016;43:621-30.
Brown JS, Zuydam AC, Jones DC, Rogers SN, Vaughan ED. Functional outcome in soft palate reconstruction using a radial forearm free flap in conjunction with a superiorly based pharyngeal flap. Head Neck 1997;19:524-34.
McCombe D, Lyons B, Winkler R, Morrison W. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg 2005;58:306-11.
Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, et al
. To thin or not to thin: The use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003;56:409-13.
Rieger J, Bohle Iii G, Huryn J, Tang JL, Harris J, Seikaly H. Surgical reconstruction versus prosthetic obturation of extensive soft palate defects: A comparison of speech outcomes. Int J Prosthodont 2009;22:566-72.
Lv M, Shen Y, Li J, Zhang C, Zhu H, Sun J. Immediate reconstruction of soft palate defects after ablative surgery and evaluation of postoperative function: An analysis of 45 consecutive patients. J Oral Maxillofac Surg 2014;72:1397-406.
[Figure 1], [Figure 2]
[Table 1], [Table 2]