Versatility of the Angularis Oris Axial Pattern Flap for Facial Reconstruction

Surgical reconstruction of a composite nasomaxillary and superior labial defect in a dog with a fascia lata graft, titanium mesh implant and angularis oris axial pattern flap

Objective

To document the successful surgical reconstruction of a composite nasomaxillary and superior labial defect using a fascia lata graft, titanium mesh and angularis oris axial pattern flap in a dog.

Case summary

An estimated 2-year-old female intact mixed-breed dog was presented with a composite (hard and soft tissue) nasomaxillary defect, suspected to be caused by a chemical burn. Physical examination revealed nasal discharge, exposed bilateral maxilla and nasal bone, nasomaxillary fistula with air movement, and intrinsic discoloration of the left maxillary canine tooth. The soft tissue lesion extended from the nasal planum rostrally to the medial canthus of the left eye distally and from the right maxillary bone to include a full thickness loss of the left maxillary labium laterally. Computed tomographic images of the head showed chronic osteomyelitis of the maxilla, zygomatic and nasal bones with nasomaxillary fistula and numerous exposed roots of the left maxillary premolars. Staged surgical procedures to address the dentition and nasomaxillary defect were planned. The first procedure consisted of the extraction of periodontally compromised left maxillary premolars, and standard root canal therapy of bilateral maxillary canine teeth. The second procedure consisted of debridement of the non-vital soft and hard tissues and surgical reconstruction of the nasomaxillary defect after virtual surgical planning. Head computed tomography performed 5 months post-operatively revealed a decrease in the size of the osseous defect as well as the resolution of rhinitis.

Clinical relevance

This case demonstrates the feasibility of using a combination of soft tissue graft, titanium mesh, and axial pattern flap in managing nasomaxillary defects. Such defects can lead to chronic rhinitis, infection, discomfort, and long-term morbidity. This case report provides a novel but practical approach for managing defects in the nasomaxillary region in dogs.

Random mucosal rotating flaps for rostral to mid maxillary defect reconstruction: 26 dogs (2000-2019)

OBJECTIVES

To evaluate the feasibility and the complications following single or double random mucosal rotating (transposition or interpolation) flaps for the closure of rostral to mid maxillary defects in dogs.

MATERIALS AND METHODS

Medical records of dogs treated with single or double random mucosal rotating flaps after maxillectomy for oral lesions or traumatic loss of tissue, were evaluated. Clinical findings, surgery performed, outcome and postoperative complications (major and minor) were extracted.

RESULTS

Twenty-six client-owned dogs were retrospectively included. Dogs underwent maxillectomy for canine acanthomatous ameloblastomas (9), oral squamous cell carcinomas (4), peripheral odontogenic fibromas (4), oral melanomas (3), oral fibrosarcomas (2), dentigerous cysts (2) and oral osteosarcoma (1) and trauma resulting in an oronasal fistula (1). Twenty-three dogs underwent a single transposition or interpolation flap and three dogs were treated with a double transposition flap. Postoperative complications, including dehiscence or flap necrosis, occurred in six dogs.

CLINICAL SIGNIFICANCE

Random mucosal rotating (transposition or interpolation) flaps are versatile when used to close rostral maxillary defects in dogs. Postoperative complications appear to be more likely when these flaps are used to close mid maxillary defects.

Evaluation of Survival of Subdermal Plexus Skin Flaps in 8 Cats After Injection of Platelet Rich Plasma

The aim of the present study was to evaluate the effect of platelet-rich plasma injection on the survival of experimentally developed subdermal plexus skin flaps in cats. Two flaps, 2 cm wide and 6 cm long were created bilaterally in the dorsal midline in 8 cats. Each flap was randomized to 1 of 2 groups: platelet-rich plasma injection and control. After flap development, the flaps were immediately placed back on the recipient bed. Then 1.8 mL of platelet-rich plasma was equally injected into 6 different parts of the treatment flap. All flaps were evaluated macroscopically daily and on days 0, 7, 14, and 25 by planimetry, Laser Doppler flowmetry, and histology. Mean flap survival on day 14 was 80.437 % (±22.745) for the treatment group and 66.516 % (±24,12) for the control group with no statistically significant difference between the 2 groups (P = .158). Histologically, a significant difference was found between the base of the PRP and the control flap in edema score on day 25 (P = .034). In conclusion, there is no evidence to support the use of platelet-rich plasma in subdermal plexus flaps in cats. However, the use of platelet-rich plasma may aid in reducing edema of subdermal plexus flaps.

Buccal transposition flap for closure of maxillary lip defects in 5 dogs

OBJECTIVE

To describe the technique and outcomes of the closure of maxillary lip defects using a buccal transposition flap and to identify potential routes of vascular supply to the flap.

ANIMALS

Five dogs treated clinically and 1 cadaveric dog head.

STUDY DESIGN

Short case series and cadaveric study.

METHODS

A left maxillary labial defect and a buccal transposition flap were created on a cadaver head. Iodinated contrast was injected into the left common carotid artery and computed tomography was performed to assess the vascular supply. Medical records were reviewed for all dogs that underwent tumor excision with maxillary lip resection, reconstructed with a buccal transposition flap.

RESULTS

The buccal transposition flap was perfused by branches of the angularis oris artery and superior labial artery. Five dogs were included in this study. All flaps survived. Three dogs developed postoperative complications, including oronasal fistula (n = 2) and partial flap dehiscence (n = 1). The cosmetic and functional outcomes were considered satisfactory in all cases.

CONCLUSION

Buccal transposition flaps for the closure of large maxillary lip defects provided adequate functional and cosmetic outcomes. The buccal transposition flap had vascular contributions from the angularis oris artery and the superior labial artery.

Virtual surgical planning and 3D printing: Methodology and applications in veterinary oromaxillofacial surgery

Virtual surgical planning is the process of planning and rehearsing a surgical procedure completely within the virtual environment on computer models. Virtual surgical planning and 3D printing is gaining popularity in veterinary oromaxillofacial surgery and are viable tools for the most basic to the most complex cases. These techniques can provide the surgeon with improved visualization and, thus, understanding of the patients' 3D anatomy. Virtual surgical planning is feasible in a clinical setting and may decrease surgical time and increase surgical accuracy. For example, pre-operative implant contouring on a 3D-printed model can save time during surgery; 3D-printed patient-specific implants and surgical guides help maintain normocclusion after mandibular reconstruction; and the presence of a haptic model in the operating room can improve surgical precision and safety. However, significant time and financial resources may need to be allocated for planning and production of surgical guides and implants. The objectives of this manuscript are to provide a description of the methods involved in virtual surgical planning and 3D printing as they apply to veterinary oromaxillofacial surgery and to highlight these concepts with the strategic use of examples. In addition, the advantages and disadvantages of the methods as well as the required software and equipment will be discussed.

Evaluation of the superior and inferior labial musculomucosal flaps in cats: An angiographic study and case series

OBJECTIVE

To evaluate the angiosomes of the superior and inferior labial arteries in the cat and describe the use of a musculomucosal axial pattern flap incorporating each artery for reconstruction of palatal defects in cats.

STUDY DESIGN

Cadaveric study and a series of two clinical cases.

SAMPLE POPULATION

Five feline cadavers and two client-owned cats.

METHODS

The common carotid arteries of five feline cadavers were injected with barium sulfate. Radiographs of excised tissue specimens were examined to map the location of the superior and inferior labial arteries and to visualize each angiosome available for an axial pattern flap. Labial musculomucosal flaps were utilized to reconstruct palatal defects in two live cats.

RESULTS

The superior and inferior labia were predominantly perfused by the superior and inferior labial arteries, respectively, and the angiosome of each artery encompassed the majority of its respective labium. Comparative positive contrast angiograms revealed the vascular supply was located within the musculomucosal layer. Reconstruction of recurrent palatal defects utilizing musculomucosal flaps based on these angiosomes in two clinical cases was successful with complete survival of the flaps.

CONCLUSION

The upper and lower lips were found to have robust vascular supplies within the musculomucosal layer which can support musculomucosal axial pattern flaps.

CLINICAL SIGNIFICANCE

This information provides the veterinary surgeon with additional surgical options for reconstruction of central and caudal palatal defects in the cat.

The pinna composite flap for wound reconstruction in a dog

OBJECTIVE

To report the surgical technique and outcome of the use of a pinna composite flap for reconstruction of a wound defect following wide surgical resection of a mast cell tumor.

ANIMALS

A 4-year-old female spayed golden doodle.

STUDY DESIGN

Clinical case report.

METHODS

A dog with a histologically confirmed cutaneous mast-cell tumor at the base of the ear was treated with a wide surgical resection, including total ear canal ablation and lateral bulla osteotomy. The defect could not be closed primarily and, as a result, the defect was reconstructed with a composite pinna flap.

RESULTS

Partial avascular necrosis of the distal aspect of the composite flap required debridement and closure 13 days after the initial surgery. The flap was fully healed at 27 days postoperatively. The dog had facial nerve paralysis, which had not resolved by 45 weeks postoperatively.

CONCLUSION

The surgical technique described in this report is novel. The use of the pinna as a composite flap is a novel reconstructive option for dorsal and dorsolateral head wounds.

Angularis oris axial pattern flap as a reliable and versatile option for rostral facial reconstruction in cats

OBJECTIVE

To evaluate outcomes associated with the use of an angularis oris axial pattern flap (AOAPF) for rostral facial reconstruction in cats.

ANIMALS

Nine adult client-owned cats.

STUDY DESIGN

Short case series.

METHODS

Ten AOAPF were performed in nine cats after resection of a tumor. Wounds were located at the nose, infraorbital, supraorbital, frontal, eye, and ear canal region. Orbital exenteration (n = 3), pinnectomy (n = 2), nasal planum resection, total ear canal ablation (n = 2), and partial eyelid reconstruction (n = 3) were performed.

RESULTS

Short-term postoperative complications included flap edema (n = 10), suture dehiscence (n = 3), and distal tip necrosis (n = 3). All wounds resulting from minor complications healed by second intention in 5-15 days. Long-term complications included epiphora (n = 2), frequent grooming around the eyes (n = 2), and enucleation due to corneal ulcer secondary to impaired postoperative eyelid function (n = 1). Tumor recurrence occurred in 3 cases.

CONCLUSION

The AOAPF was a versatile and reliable option for rostral facial reconstruction in cats with acceptable long-term outcomes.

Superficial temporal axial pattern flap for facial reconstruction of skin defects in dogs and cats

OBJECTIVES

Report the use, complications and outcome of the superficial temporal axial pattern flap (STA) when used for closure of skin defects localised to the maxillofacial region in dogs and cats.

MATERIALS AND METHODS

Multi-centre retrospective cohort study. Medical records of dogs and cats treated with a STA flap for closure of skin defects were reviewed. Information regarding signalment, reason for axial pattern flap use, flap size, flap healing, postoperative complications including need for surgical revision and overall outcome were collected.

RESULTS

Nineteen patients were included: nine dogs and 10 cats. Indications for the STA flap included closure of defects following excision of tumours (18/19, 94.7%) and fungal granuloma resection (1/19, 5.2%). 100% flap survival occurred in 17 of 19 flaps (89.4%). Postoperative complications occurred in eight of 19 flaps (42.1%). A major complication of full thickness partial necrosis of the flap occurred in one of 19 cases (5.2%), where the flap length exceeded recommended guidelines. Minor complications related to the flap were seen in four of 19 cases (21%). This included partial thickness flap necrosis, flap oedema and wound discharge. Complications related to the location of surgery (5/19, 26.3%) included mild ectropion, mild exposure of the eye, reduced ability to blink and subcutaneous emphysema.

CLINICAL SIGNIFICANCE

The STA flap is a good option for closure of a skin defect localised to the maxillofacial region. STA flaps were associated with a high percentage of survival and a low incidence of major complications.

Reconstruction of a large nasal-facial defect using an augmented temporal myocutaneous tube flap in a dog

The muzzle region of dogs contains various composite tissues, which are challenging to recreate during reconstruction. Small or moderate facial/nasal defects can be closed primarily or left for second‐intention healing. However, larger defects require the application of composite tissue or labial advancement flaps. Axial pattern flaps based on the caudal auricular artery, superficial temporal artery (STA), angularis oris artery, and other cutaneous arteries have been reported. In our case, we aim to report the reconstruction of a large composite defect of the rostral and dorsal nasal regions in a dog using an augmented, axial myocutaneous flap based on bilateral STAs. This is a clinical report on a spayed female mixed‐breed dog (age, 7 years; weight, 15 kg), in which a large‐scale nasal–facial composite tissue defect was surgically reconstructed using an axial myocutaneous flap based on bilateral STA branches. A delay technique was applied to prefabricate the flap to enrich the blood supply. New nostrils were created on a folded, rostral hard palate. As a result, the axial tube rotational flap was successfully transferred. The use of delay technique for prefabricating the tube flap optimized its size and survival. In addition to the folded rostral hard palate, the flap fully closed the defects on the face and nose. Functional and cosmetic outcomes were satisfactory, with minimal donor‐site morbidity. In, conclusion, a large‐scale nasal–facial defect in a dog was successfully reconstructed using an augmented tube pedicle flap based on the bilateral STAs, which may, thus, be used to repair very large facial‐nasal defects in dogs.

A large‐scale nasalfacial defect in a dog was successfully reconstructed using an augmented tube pedicle flap based on the bilateral STAs, which may, thus, be used to repair very large facial‐nasal defects in 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.

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.