Modification of the Superficial Cervical Axial Pattern Skin Flap for Oral Reconstruction

Reverse Pedicle U-Shaped Palatal Flap: An Innovative Technique for Repair of Severe Caudal Palatal Defects in Two Dogs

An acquired palatal defect in dogs is a pathologic condition in which there is communication between the oral cavity and nasal cavities, maxillary recesses, or orbits. Many different causes exist and must be considered. Two dogs were presented for severe palatal defects secondary to a foreign body trapped between maxillary dental arches. Numerous techniques have been previously described to repair palatal defects, and the most appropriate choice is based on the clinical features of the defect and information obtained from advanced diagnostic imaging. Acquired palatal defects are not predictable in shape, size, and location; therefore, although the literature contains many different surgical techniques, these are not always reliable. The aim of this article is to describe an innovative surgical approach to repair severe acquired caudal palatal defects in two different dogs.

Locoregional Flap Reconstruction Following Oromaxillofacial Oncologic Surgery in Dogs and Cats: A Review and Decisional Algorithm

Primary treatment of most oromaxillofacial tumors in dogs and cats is resective surgery. Management of malignant tumors may be very challenging as wide/radical free-margin surgical removal must be achieved while preserving vital functions. Removal of orofacial tumors may result in large defects exposing the oral cavity or creating a communication with the nasal, pharyngeal, or orbital cavities. Such defects require orofacial reconstruction in order to restore respiratory and manducatory functions. The veterinary surgeon must be familiar with reconstructive techniques in order to prevent the inability of closing the defect, which could lead to an insufficient resection. Small oral defects exposing the nasal cavity are best closed with local random mucosal flaps. Closure of large oral defects may be better achieved with a facial or major palatine-based axial-pattern flap. Small to moderate facial defects can be closed with local advancement or transposition skin flaps. Reconstruction of large facial defects often requires the use of locoregional axial pattern flaps such as the caudal auricular, the superficial temporal, or the facial (angularis oris) myocutaneous axial pattern flaps. Recent publications have shown that the facial (angularis oris) flap is a very versatile and reliable flap in orofacial reconstructive surgery. A surgical decision algorithm based on the size, nature, and location of the defect is proposed.

Staged mandibular lip flap for closure of a large palatal defect after maxillectomy in a dog

OBJECTIVE

To report closure of an oronasal defect secondary to maxillectomy with a staged mandibular lip flap.

STUDY DESIGN

Case report ANIMALS: One 9-year-old female spayed golden retriever.

METHODS

A combined dorsolateral and intraoral approach was used to perform a central maxillectomy to excise a 2.4- × 2- × 2.7-cm oral osteosarcoma with 1-cm margins. A buccal mucosal flap was used to close the palatal defect but the site subsequently dehisced. A staged mandibular lip flap was performed to close the defect. An incision was made on the mandible at the intersection of the buccal mucosa and gingiva from the mandibular canine to the level of the commissure. A second incision was made 3 cm ventral to the lip margin. The flap pedicle was based at the commissure. The flap was rotated to cover the palatal defect from rostral to the canine tooth to the fourth premolar. A second procedure was performed 4 weeks after flap placement to desquamate the haired skin and transect the flap pedicle.

RESULTS

Partial dehiscence at the caudal aspect of the flap occurred after the first revision. The defect was closed after pedicle transection on day 41, with acceptable cosmesis. The dog was eating canned food with no evidence of discomfort 159 days after the maxillectomy. Recurrence was noted on day 270 postoperatively.

CONCLUSION

Closure of a large palatal defect with a staged mandibular lip flap led to good cosmesis and function.

Excision of Extensive Orbitozygomaticomaxillary Complex Tumors Combining an Intra- and Extraoral Approach With Transpalpebral Orbital Exenteration

The junction of the bones of the orbit, caudal maxilla and zygoma intersect to form an anatomically intricate region known as the orbitozygomaticomaxillary complex (OZMC). Given the critical role of the OZMC in the structure, function and esthetics of the skull and midface, tumors in this region present unique challenges to the oromaxillofacial surgeon. Attempts to achieve histologically clean tumor margins in a cosmetically pleasing manner requires excellent intra-operative visualization. Additionally, minimized intra-operative and post-opertive complications is of paramount importance. In this manuscript we describe a combined intra- and extraoral approach to extensive tumors of the OZMC that incorporates orbital exenteration as a technique, which allows for excellent intra-operative visualization and mitigate intra- and post-operative complications. In addition, we describe our experience utilizing the technique in five clinical cases.

Hard palate defect repair by using haired angularis oris axial pattern flaps in dogs

OBJECTIVE

To describe the repair of large hard palate defects with a haired angularis oris axial pattern flap (HAOF) and to report the postoperative outcome.

STUDY DESIGN

Anatomical cadaver study and short case series.

ANIMALS

One cadaver and three dogs with neoplasia of the caudal hard palate.

METHODS

Large caudal and central hard palate defects were reconstructed by using the HAOF. The flap, composed of full-thickness skin and buccal mucosa, was rotated at the base of the angularis oris artery. The haired surface of the skin flap was placed facing into the oral cavity.

RESULTS

Reconstruction of defects extending as far rostral as the maxillary canine tooth were feasible on the cadaver. The flap in dog 1 healed without complication and was intact at day 649 after surgery. Two minor areas of dehiscence were noted in dog 2, without further evidence of complications at 1331 days after surgery. Dog 3 had upper respiratory obstructive noise due to swelling immediately after surgery. These signs resolved, but local recurrence of the tumor prompted euthanasia at day 86.

CONCLUSION

Anatomical studies provide evidence that the HAOF can be used to reconstruct caudal and central hard palate defects extending to the maxillary canine teeth. Its clinical use led to successful closure of such defects in three dogs.

CLINICAL SIGNIFICANCE

HAOF provides an alternative for reconstruction of large defects of the caudal and central hard palate.

Biologic Basis of De-Epithelialized Transverse Platysma Flap for Oral Cavity Reconstruction

Introduction

The inferiorly and laterally based platysma myocutaneous flap contains hair in some ethnics; therefore, it is required to change the myocutaneous flap to myofascial flap to prevent the hair growth after its transfer to the oral cavity.

Materials and Methods

Five male mongrel dogs were selected for this study. De-epithelialized laterally based platysma flap, muscle part facing the oral cavity, was used for buccal reconstruction. The clinical healing process was photographed every week. After 40 days, biopsy specimens were obtained from the transferred flap.

Results

According to the results, all flaps survived. At the end of the first week, the flap was covered with fibrinous exudate. On the third week, only the center of the transferred flap was not covered with mucosa. Within 40 days, the flap was distinguishable clinically from the adjacent buccal mucosa just by hypopigmentation. Hematoxylin and eosin staining of the biopsy specimens taken on day 40 showed thin stratified squamous epithelium covered with a tiny parakeratin layer.

Conclusion

Myofascial platysma flap, muscle part faced oral cavity, survives and undergoes mucosalization after adaptation to the recipient oral tissue.

Composite Resection of Tumors of the Rostral Maxilla and Dorsolateral Muzzle Utilizing an Upper Lip-Sparing, Combined Approach in Dogs

Tumors of the rostral maxilla that involve both the oral mucosa and the dermis or subdermis of the dorsolateral muzzle provide unique challenges for the oromaxillofacial surgeon. Traditionally described approaches to such lesions may involve an intraoral incision that extends and involves the upper lip to envelope the involved dermis of the dorsolateral muzzle. However, such an approach unnecessarily resects upper lip tissue resulting in a large defect that likely requires advanced skin flaps or grafts for reconstruction. Such flaps are technically challenging and introduce potential for significance postoperative complications. In this article, we provide a detailed description a combined intra- and extraoral approach that allows for composite resection of tumors of the rostral maxilla that also involve the dorsolateral muzzle. The described technique allows for excellent intraoperative visualization and provides a superior cosmetic outcome that minimizes postoperative complications. In addition, we describe our experience utilizing the technique in three clinical cases.

Axial Pattern Flaps

Axial pattern flaps are based on a direct cutaneous artery and vein supplying a segment of skin. They provide a large, robust option for large wound closure. Many different axial pattern flaps have been described to provide options for closure of wounds located from the nose to the tail. All axial pattern flaps require good surgical technique and careful attention to detail while developing of the flap.

Complications of the angularis oris axial pattern buccal flap for reconstruction of palatine defects in two dogs

CASE REPORT

Complications associated with surgical reconstruction of hard palate defects with a buccal mucosal flap based on the angularis oris artery and vein in two dogs are described. Distal flap necrosis occurred in both cases, but the flaps were successfully salvaged by division of the original flap pedicle and rotation of the flap material into the remaining defect. Postoperative dysphagia was observed in both dogs until flap revision. Salvage of the intact distal portion of the flap following division of the direct artery and vein 14 days postoperatively is discussed.

CONCLUSION

The angularis oris axial pattern buccal flap is an option for reconstruction of large defects of the hard palate. Survival of the flap can be improved by removal of teeth likely to cause occlusal trauma to the flap's pedicle. In the event of distal flap necrosis, the repair may be salvaged by rotation of the remaining flap into the defect, following establishment of vascular supply from adjacent tissue.

Oronasal fistula repair utilizing a temporalis muscle flap in a dog with severe trismus

A 9 yr old spayed female cocker spaniel presented for evaluation of an invasive maxillary squamous cell carcinoma. Curative intent surgery and radiation therapy allowed for local control of the neoplasm; however, the development of a persistent oronasal fistula prevented a complete recovery. A temporalis myofascial rotation flap allowed for successful resolution of the maxillary defect. Implementation of the flap was relatively simple and was associated with few complications.

Free Auricular Cartilage Autograft for Repair of an Oronasal Fistula in a Dog

An eight-year-old female/spayed Pomeranian dog was presented for surgical treatment of an acquired right oronasal fistula. The maxillary right canine tooth had been extracted non-surgically 7-weeks prior to presentation. Clinical signs were consistent with an oronasal fistula during this time period. Oral examination showed an oronasal fistula in the area of the extracted tooth. The referring veterinarian performed simple debridement and suturing with subsequent recurrence of the oronasal fistula. This case report describes the successful surgical treatment of an acquired oronasal fistula with a free auricular cartilage autograft and reviews techniques described for oronasal fistula repair, including free auricular cartilage autografts.

Facial reconstructive surgery

Reconstruction of facial defects can be very challenging, even in the hands of an experienced surgeon. Most defects can be repaired using local available tissues. Lip defects can be reconstructed using geometric closure techniques and advancement of local tissues. Forehead defects can be reconstructed using skin grafts, caudal auricular flaps, or rotational or transposition flaps. Care must be taken to minimize tension on eyelids and maintain the integrity of the facial nerve. Cheek defects can be reconstructed using local advancement, superficial temporal, omocervical, and caudal auricular flaps. The bridge of the nose can be very difficult to reconstruct due to a paucity of local tissues; however, skin grafts, indirect pedicle flaps, and superficial temporal flaps can be considered. .

Use of Local and Axial Pattern Flaps for Reconstruction of the Hard and Soft Palate

There are numerous conditions that may result in defects of the hard and soft palate. Reconstruction of these defects may be difficult due to anatomical limitations and limited tissue availability. The majority of palate defects, even when large, may be closed using local and/or axial pattern flaps, while other more advanced techniques such as free tissue transfer and prosthetic implants are required in a smaller number of cases. This article describes the use of local and axial pattern flaps in the reconstruction of the hard and soft palate.

Investigation and clinical application of a novel axial pattern flap for nasal and facial reconstruction in the dog

OBJECTIVE

To describe the vascular supply to a facial skin flap based at the commissure of the lip in the dog and report on its use in four dogs.

STUDY DESIGN

Experimental and prospective clinical study. Animals Five canine cadavers and four client-owned dogs.

METHODS

In the cadavers, the ventral aspect of the zygomatic arch, the ventral margin of the caudal mandible and the wing of the atlas were marked as anatomical boundaries of a skin flap that was elevated from the subcutaneous tissues to the level of the medial canthus of the eye. Methylene blue dye and barium sulphate solution were independently infused through a common carotid (three dogs) or facial artery (two dogs) catheter. Distribution of dye throughout the harvested skin was assessed subjectively. After contrast infusion the flap was excised and radiographed. The technique was used to reconstruct large facial or nasal defects in four dogs after tumour or skin lesion excision.

RESULTS

Cadaver dissections and contrast studies clearly demonstrated three direct cutaneous arteries, the superior and inferior labial arteries and the angularis oris artery, arborising within the base of the flap. A separate direct cutaneous branch of the angularis oris artery was identified. An arterial plexus was identified within the distal flap, within which this artery communicates with the transverse facial artery and a cutaneous branch of the masseteric artery. Dye infusion caused discolouration of the elevated skin and vasculature within the flap. The flap survived in all clinical cases with marginal distal necrosis in one dog.

CONCLUSIONS

The complex facial flap described is perfused by three direct cutaneous arteries and functions reliably in clinical cases.

Rectus Abdominis Free Muscle Flap for Reconstruction in Nine Dogs

OBJECTIVE

To evaluate the clinical use and outcome of a rectus abdominis microvascular free flap for wound closure in dogs.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n=9) with complex extremity or oral wounds.

METHODS

Medical records (2002-2006) of dogs that had a rectus abdominis free tissue transfer to close an extremity or oral wound were reviewed.

RESULTS

Nine dogs were identified: 5 had distal extremity wounds, 3 had oral palatal defects, and 1 had a large hygroma excised. A rectus abdominis free tissue transfer with a caudal epigastric vascular pedicle was successfully used for management of these wounds. No major complications occurred with the donor site and a good cosmetic and functional outcome occurred in all dogs.

CONCLUSION

The rectus abdominis is a versatile muscle that can be used for reconstructing cutaneous and oral defects with repeatable success.

CLINICAL RELEVANCE

Free tissue transfer of the rectus abdominis muscle is a clinically useful technique for closure of a variety of difficult soft tissue wounds.

Repair of Oronasal Fistulae Using Auricular Cartilage Grafts in Five Cats

OBJECTIVE

To describe repair of chronic palatine defects in cats, with free cartilage graft harvested from either the pinna (scapha) or vertical ear canal (annular cartilage).

STUDY DESIGN

Retrospective study.

ANIMALS

Cats (n=5) with chronic oronasal fistula.

METHODS

Cartilage was harvested from either the scapha or annular cartilage and epithelium removed. After preparation of the edges of the palatal defect by separation of the oral and palatal mucosa circumferentially, the graft was inserted between the epithelial layers and secured without tension. The graft acted as a scaffold for migration of granulation tissue and epithelialization.

RESULTS

Oronasal fistulae were successfully repaired in 5 cats (3 pinna grafts; 2 annular cartilage grafts); 1 cat required a second graft after the first graft was dislodged.

CONCLUSIONS

Auricular cartilage provides a reliable framework for repair of oronasal fistulae in cats.

CLINICAL RELEVANCE

Chronic oronasal fistulae refractory to conventional repair can be treated by use of auricular free graft (pinna or annular cartilage) without disfigurement. Use of annular cartilage to support palatal repairs offers surgeons an additional option when other methods have failed. We recommend using conchal cartilage as the initial treatment approach for repair of small oronasal fistulae in cats.