Intraoral defect coverage with muscle flaps

Prelamination of the Radial Forearm Free Flap Using Free Full-Thickness Eyelid Skin Grafts: A New Approach for Intraoral Defect Reconstruction

ABSTRACT

Free flap transfer for reconstruction of intraoral defects is a common procedure in oral and maxillofacial surgery. For tumor-related defects, the radial forearm flap is widely used for soft tissue restoration. However, transfer of free skin grafts to the donor site region is often required for wound closure after free flap harvesting, resulting in esthetic disturbances due to shrinkage of the grafted skin, attendant scarring, or mismatches in skin texture or color. Furthermore, free flap transfer may result in hair follicle transfer into the oral cavity, causing unfavorable intraoral hair growth in adult men in particular. Free flap prelamination can help reduce the potential disadvantages of free flaps, in terms of both flap design and size and donor site morbidity. For surgical treatment of oral cancer in middle-aged and elderly patients, eyelid dermatochalasis may present as a comorbidity leading to esthetic impairments or, in cases involving the upper eyelid, even a reduced field of view. In these cases, bilateral blepharoplasty can reduce the excess eyelid skin. The present study is the first to attempt to use excised skin after bilateral blepharoplasty as full-thickness skin grafts for radial forearm free flap prelamination. This approach combined surgical therapy of eyelid dermatochalasis with free flap prelamination, thereby avoiding the need to harvest free skin grafts from other anatomically healthy regions to close the donor site defect and preventing the accompanying disadvantages. The reconstruction results and clinical outcomes of patients revealed that radial forearm free flap prelamination using bilateral free full-thickness eyelid skin grafts was an easy and feasible method for intraoral defect reconstruction. In particular, this approach could avoid intraoral hair growth and additional skin grafting from other healthy anatomical regions, yielding good esthetic and functional results at the flap's recipient and donor sites.

Histological Changes in Nasolabial Cutaneous Flaps Employed in Intraoral Reconstruction

INTRODUCTION

Nasolabial cutaneous flaps have been routinely used to reconstruct intraoral defects. The purpose of this study was to study histological changes that may occur in the skin flap as a result of its exposure to a new environment.

PATIENTS AND METHODS

Thirteen patients took part in this study. Fusiform tissue specimens were obtained from the intraoral cutaneous portion of the flap. Biopsy specimens were also taken from the skin of nasolabial region and from the buccal mucosa to serve as control. Thickness of stratum corneum, degree of inflammatory infiltration and number of skin appendages were evaluated. Periodic-acid Schiff (PAS) staining was also performed to identify the presence of hyphae.

RESULTS

The characteristic features of the skin are almost always maintained, although the thickness of stratum corneum and the number of skin appendages are often significantly reduced. In two patients the inflammatory infiltration was intense and accompanied by elimination of skin appendages and stratum corneum. These flaps tend to mimic mucosa macroscopically. In four patients fibrosis was histologically demonstrated. These flaps resembled atrophic skin macroscopically. Hyphae could not be identified with PAS staining in this study. Koilocytes, which are indicative of HPV infection, were identified in two flap specimens.

CONCLUSIONS

Intraorally placed nasolabial flaps may undergo a variety of histological and macroscopical changes. In the majority of cases the intraoral cutaneous flap maintains skin features, except if it becomes heavily infiltrated with inflammatory cells. Inflammation occurs for unknown reasons and results in a mucosa-like microscopic and macroscopic appearance of the intraorally placed flap.

Repair of Recurrent Cleft Palate with Free Vastus Lateralis Muscle Flap

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

Temporalis myofascial flap for primary cranial base reconstruction after tumor resection

OBJECTIVE

To evaluate the use of the temporalis myofascial flap in primary cranial base reconstruction following surgical tumor ablation and to explain technical issues, potential complications, and donor site consequences along with their management.

DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PARTICIPANTS

Forty-one consecutive patients receiving primary temporalis myofascial flap reconstructions following cranial base tumor resections in a 4-year period.

MAIN OUTCOME MEASURES

Flap survival, postoperative complications, and donor site morbidity.

RESULTS

Patients included 37 males and 4 females ranging in age from 10 to 65 years. Two patients received preoperative and 18 postoperative radiation therapy. Patient follow-up ranged from 4 to 39 months. The whole temporalis muscle was used in 26 patients (63.4%) and only part of a coronally split muscle was used in 15 patients (36.6%). Nine patients had primary donor site reconstruction using a Medpor((R)) (Porex Surgical, Inc., Newnan, GA) temporal fossa implant; these had excellent aesthetic results. There were no cases of complete flap loss. Partial flap dehiscence was seen in six patients (14.6%); only two required surgical débridement. None of the patients developed cerebrospinal leaks or meningitis. One patient was left with complete paralysis of the temporal branch of the facial nerve. Three patients (all had received postoperative irradiation) developed permanent trismus.

CONCLUSIONS

The temporalis myofascial flap was found to be an excellent reconstructive alternative for a wide variety of skull base defects following tumor ablation. It is a very reliable, versatile flap that is usually available in the operative field with relatively low donor site aesthetic and functional morbidity.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

OBJECTIVES/HYPOTHESIS

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single-stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

STUDY DESIGN

In a retrospective and prospective case series, this study evaluated the surgical outcomes of 72 patients undergoing surgical resection and reconstruction of the hard and soft palate using a TMF. Of this series, 25 patients underwent nasalence and swallowing quality-of-life testing to determine speech and swallowing function following this procedure.

METHODS

Reliability, safety, and effectiveness data endpoints on TMF reconstruction were collected and analyzed. Instrumental measures of nasalence (KayPentax Nasometer, Lincoln Park, NJ) and swallowing quality of life measures (MD Anderson Dysphagia Inventory [MDADI] were acquired.

RESULTS

All TMF's were successfully transferred with complete healing of the oncologic defect. The group mean nasalence for connected speech tasks were within normal limits for connected speech--high- and low-pressure tasks (M = 21% and M = 17%). The group mean nasalence scores for sustained vowels were mildly affected (M = 26%). The group mean MDADI score was 79 (SD = 16), indicating good to mildly affected swallowing quality of life. Neither nasalence nor MDADI scores appeared to vary as a function of defect region.

CONCLUSIONS

The TMF is an oncologically safe and effective method of palate reconstruction that affords excellent quality of life to appropriately selected patients without reliance on other reconstructive techniques.

Lining the mouth floor with prelaminated fascio-mucosal free flaps: clinical experience

Soft-tissue defects of the mouth floor need thin, foldable, and pliable tissues able to preserve local anatomy as well as chewing, phonation, and deglutition. The oral mucosa is made of a stratified, nonkeratinized, epithelium-secreting mucus, which lubricates the oral cavity and facilitates tongue movements. No flap exists that can reproduce the physiology of the oral mucosa better than the oral mucosa itself. Prefabrication of mucosal flaps may represent the best solution. Therefore, 10 consecutive cases of mouth floor cancer were treated with prelamination of the fascia antibrachialis with mucosal grafts obtained from the healthy cheek, and with subsequent transplantation 3 weeks later. A significant increase in mucosal graft surface was seen in all cases, with a mean size twice the original. All flaps healed uneventfully. Follow-up time ranged between 2-60 months (average, 26.6 months). Morphological and functional results were excellent. Tongue motility, speech intelligibility, and swallowing were reestablished in all treated cases. Mucosal prelamination of the forearm fascia is feasible and allows physiological reconstruction of oral cavity defects up to 6 x 4 cm.

The temporalis muscle flap in reconstruction of intraoral defects: an appraisal of the technique

PURPOSE

The purpose of this article is to review the experience of the authors in the use of the temporalis muscle flap for reconstruction of intraoral defects.

PATIENTS AND METHODS

This is a retrospective review of the use of the temporalis muscle flap for reconstruction of different types of intraoral defects in 8 patients. All patients in this series previously wore obturators as a nonsurgical treatment of their defects. Criteria used to evaluate the results of this technique included flap necrosis, facial nerve deficit, limitation of mandibular range of motion, and cosmetic deformity from scarring of the incision line or from loss of muscle volume in the temporal fossa. The patients were also evaluated for their degree of satisfaction with their speech and mastication with the obturator preoperatively and with the flap postoperatively. This article also reviews the success rates and complications with use of the temporalis muscle flap reported in the English-language literature during the past 14 years.

RESULTS

All 8 patients in this series had their defects successfully reconstructed, completely eliminating any further need for prosthetic obturation of the defect. There were no incidents of flap necrosis, facial nerve deficit, or long-term changes in mandibular range of motion. Slight temporal hollowing was seen in the first 3 patients. Results of the literature review also showed a high success rate and a low incidence of complications with use of this flap.

CONCLUSIONS

The temporalis flap is a useful, reliable, and versatile option for reconstruction of moderate to large sized defects. The muscle can provide abundant tissue, with minimal to no functional morbidity or esthetic deformity in the donor site.

Indications for the vastus lateralis flap in oral and maxillofacial surgery

OBJECTIVE

To find out the applications, usefulness and advantages of the microsurgically anastomosed vastus lateralis flap. We evaluated the results of 60 consecutive oral and maxillofacial reconstructions and established typical indications for use of this flap.

DESIGN

The transplant was applied as a pure muscle flap in 17 cases, four of those being a split-skin flap for coverage of defects on the scalp. Further reconstructions were done with myocutaneous flaps for the tongue (n = 13), floor of the mouth (n = 16) and external skin defects (n = 6) as well as to close perforating defects (n = 8).

RESULTS

The long and high-calibre vascular pedicle, the unvarying anatomy, and the time-saving possibility of simultaneously resecting the tumour and raising the flap in the head and neck region proved to be particularly advantageous during flap transfer. The best results were obtained in extensive, deep, or perforating defects and in tongue reconstruction; neuromuscular connection of the transplant is possible. Pure muscle transplants have only a few indications for application in the oral cavity because of their tendency to shrink. Donor site morbidity was generally low; the flap was lost in 5 cases.

CONCLUSION

This hitherto rarely used transplant is well-suited for maxillofacial reconstructions if the correct indications apply.

A comparative study of epithelialization of subcutaneous fascial flaps and muscle-only flaps in the oral cavity. A rabbit model

Epithelialization of subcutaneous fascial flaps and muscle-only flaps used for reconstruction of the oral mucosa were studied in a rabbit model. Angiography was performed to help to design a subcutaneous cervical fascial flap and a cleidomastoid muscle-only flap. These flaps were transferred into a mucoperiosteal defect on the mandibular alveolus. The flaps were gradually infiltrated by acute inflammatory cells from the periphery and then replaced by granulation tissue originating from the oral mucosa. The epithelialization was by secondary intention. An epithelial tongue from the surrounding epithelium migrated onto the granulating flaps with eventual coverage after three weeks. After two months, the muscle-only flap was covered by a poorly organized epithelium, different from the highly uniform epithelium in the fascial flap. The granulation tissue which replaced the muscle-only flap matured to fibrous tissue, associated with severe contraction. This was characterized by dense regular collagen fibers, no elastic fibers, and few capillaries, while the fibrous tissue which replaced the fascial flap was characterized by random collagen and elastic fiber morphology and numerous dilated blood vessels, and was associated with mild contraction. This experiment supports the view that the different extracellular matrices of these flaps may play a role in epithelial configuration and contraction.

Experimental study of epithelialization of the muscle-only flap in the oral cavity

PURPOSE

The purpose of this study was to observe the epithelialization process of the muscle-only flap used for reconstruction of the oral mucosal defects.

MATERIALS AND METHODS

Forty-three male adult Japanese rabbits were used. A superiorly based cleidomastoid muscle flap was designed after vascular assessment. The flap was transferred into the oral cavity to cover a mucoperiosteal defect made in the mandibular alveolus. Epithelialization of the flap was histologically evaluated at designated intervals.

RESULTS

The flaps survived without ischemic necrosis. By 8 days postoperation, the flap was infiltrated by acute inflammatory cells and being replaced by granulation tissue originating from the adjacent tissues. The oral epithelial cells advanced onto this granulating muscle flap, with eventual coverage by 21 days. The granulation tissue matured to fibrous tissue with significant contraction by 2 months. At 6 months postoperation, abnormally hyperkeratinized epithelium was seen on the flap. This differed from the surrounding parakeratinized oral epithelium.

CONCLUSIONS

The muscle-only flap in the oral cavity epithelializes after the granulation process.

Temporalis myofascial flap in maxillofacial reconstruction: clinical and histological studies of the oral healing process

OBJECTIVES

To report our experience with temporalis myofascial flaps (TMF), describe the healing process of uncovered flaps in the mouth, and the histology of the repaired mucosa in the long term.

DESIGN

Prospective clinical and histological study.

SUBJECTS

36 patients who received a TMF over a 6.5 year period for serial assessment of the oral healing, 24 patients whose scars over the reconstructed area were assessed clinically, and 11 whose repaired mucosa was assessed histologically.

MAIN OUTCOME MEASURES

To follow the clinical process of oral healing of the TMF and describe the repaired mucosa healed over the flap.

RESULTS

The uncovered TMF in the mouth healed gradually starting with an acute inflammatory phase, going through chronic inflammatory and proliferative phases with eventual epithelialisation of the oral mucosa. There were no major complications. The healed mucosa showed mild scarring in 70% of cases and the repaired mucosa had characteristic histological features that were distinct from the normal mucosa.

CONCLUSION

The TMF is an extremely reliable and versatile flap for maxillofacial reconstruction which heals gradually with eventual coverage by mildly scarred repaired mucosa.