A useful flap combination in wide and complex defect reconstruction of the medial canthal region: Glabellar rotation and nasolabial V-Y advancement flaps

BACKGROUND:

Reconstruction of medial canthal defects after tumour excision is difficult owing to the thin skin of the region and the concavity of the anatomical landmarks, which enclose complex structures such as the medial canthal ligament and the lacrimal system. Local reconstruction methods for this region include secondary healing, full-thickness skin grafts, and skin flaps from the frontal, transnasal, glabellar and upper eyelid regions.

OBJECTIVE:

To demonstrate a useful combination of two local flaps in wide defects of the medial canthal region.

METHODS:

Between 1998 and 2012, a combination of glabellar rotation and nasolabial V-Y advancement flaps were used in 11 patients with wide complex defects after excision, including periosteum, of invasive basal cell carcinoma.

RESULTS:

All patients were tumour free and underwent functional and aesthetic reconstruction of the medial canthal region. There were no major complications, and no relapses were observed.

CONCLUSION:

This technique achieves good match in colour and texture, and has satisfactory results both aesthetically and functionally. In addition, donor area morbidity is minimal and surgical technique is simple.     

Microsurgical reconstruction of major scalp defects following scalp avulsion

Introduction:

Total scalp avulsion is a serious injury, commonly occurring in Indian females working with industrial and agricultural machines. Their long hairs often get caught in a rapidly revolving machines, resulting in total avulsion of scalp. Lack of education and awareness in Indian villages often result in these patients coming late to the hospitals when replantation is not possible and scalp reconstruction remains the only available option.

Materials and Methods:

We performed our study on 22 cases of scalp avulsion injury presented to us between June 2007 and April 2012 at Department of Burn, Plastic & Reconstructive Surgery, SMS Hospital, Jaipur. In all of them a free tissue transfer was performed as an elective procedure.

Results:

Twenty two patients underwent free tissue transfer and followed up for an average period of 6 months. All patients included in this study were females with mean age of 28 yrs. Five patients in our study reported with partial necrosis of the free flaps which were subsequently managed with split-thickness skin graft (STSG). Two patients reported total necrosis of the flap which was re-operated using latissimus dorsi along with serratus anterior muscle (LDSA) from the contralateral side.

Conclusion:

As scalp avulsion because of rapidly rotating machine leads to large size defect not amenable for local tissue reconstruction. We performed reconstruction using LDSA and omental free flaps with split thickness skin graft (STSG) for large scalp defect and achieved good and stable soft tissue cover with satisfactory cosmesis.KEY WORDS: Latissimus dorsi with serratus anterior flap, scalp avulsion injury, scalp reconstruction     

A new technique for one-stage total lower lip reconstruction: Achieving the perfect balance

BACKGROUND:

Reconstruction of extensive lower lip defects is difficult. The authors describe a new technique of one-stage total lower lip reconstruction, with the ultimate goal being achievement of the delicate balance between adequate mouth opening and competent mouth closure, with satisfactory aesthetic outcome.

METHODS:

The authors applied their new reconstructive technique in a patient with extensive lower lip defect following excision of squamous cell carcinoma. Bilateral inferiorly based nasolabial flaps were used for reconstruction of lower lip. For vermillion reconstruction, a bucket-handle mucomuscular flap from upper lip was designed primarily using the pars marginalis portion of orbicularis oris. Compared with previously described techniques, this procedure is unique with respect to the alignment of the nasolabial flaps in relation to one another. Furthermore, this technique of vermillion reconstruction is a one-stage procedure with minimal morbidity, enables preservation of the vascular pedicle and innervation and maintains the orientation of orbicularis oris, thus providing a competent oral sphincter. To the authors’ knowledge, this mucomuscular upper lip flap has not been described earlier and has definite advantages over the commonly used methods of vermillion reconstruction.

RESULTS:

The functional and aesthetic outcomes are satisfactory on follow-up, with normal lip movements and sensation, adequate mouth opening and oral competence, good colour and texture match with adjacent tissues, and excellent volume and quality of the vermillion. No subsequent corrective surgery is required.

CONCLUSIONS:

This technique is simple and achieves the main goals of total lower lip reconstruction in a single stage with minimal morbidity.     

Reconstruction of post-traumatic long bone defect with vascularised free fibula: A series of 28 cases

Introduction:

The severe long bone defects usually follow high-energy trauma and are often associated with a significant soft-tissue injury. The goal of management of these open long bone defects is to provide stable fixation with maintenance of limb length and soft-tissue coverage. The purpose of this article is to present the clinic-radiological outcome, complications and treatment of post-traumatic long bone defect with vascularised fibula transfer.

Materials and Methods:

Retrospective records of 28 patients were analysed who presented with post-traumatic long bone defects and in whom reconstruction with vascularised free fibula was done. Demographic data were recorded and clinical and radiological assessment was done.

Results:

Out of 28 patients in whom vascularised free fibula transfer was carried out three flaps were lost while non-union occur in three patients. Three patients developed a stress fracture of transferred free fibula in the post-operative period. Few of the patients experienced some problems in the donor leg; however, all of them improved in subsequent follow-up.

Discussion:

It is clearly evident from this study that timing of surgery plays an important role in the micro-vascular reconstruction in trauma cases. All the complication like flap loss, non-union or delayed union occur in patients in whom reconstruction was delayed.

Conclusion:

The free vascularised fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of scarred and avascular recipient sites or in patients with combined bone and soft-tissue defects. Results are best when the reconstruction is done within 1 week of trauma.KEY WORDS: Long bone defect, post-traumatic, vascularised free fibula     

Reconstruction of complex thoraco-abdominal defects with extended anterolateral thigh flap

Background:

The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage.

Materials and Methods:

From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft.

Result:

All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance.

Conclusion:

Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.     

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.KEY WORDS: Breast reconstruction, cephalic vein, free flap, head and neck reconstruction     

Pedicled omental and split skin graft in the reconstruction of the anterior abdominal wall

INTRODUCTION

The POSSG is a pedicled graft based on either the right or left gastro-epiploic arteries. It is used with a dual mesh in reconstruction of full thickness defects of anterior abdominal wall and covered by skin grafts.

PRESENTATION OF CASE

A recurrent malignant peripheral nerve sheath tumor (MPNST) of the anterior abdominal wall was excised leaving a large defect. The POSSG was used for reconstruction. A large dual mesh was placed to close the defect in the abdominal wall by suturing it to the remnant rim of abdominal muscles. The omental pedicle was brought through a keyhole in the mesh, spread out over the mesh, sutured and covered by split skin grafts. The final graft take was 90 percent.

DISCUSSION

The POSSG can be used to reconstruct any size of anterior abdominal wall defects due to the malleable nature of omentum. Its prerequisite however is a dual mesh like PROCEED. The POSSG helps keep the more complex musculofasciocutaneous flaps as lifeboats. It can be used singly where multiple musculofasciocutaneous flaps would otherwise have been required. It can be used in patients with poor prognosis of underlying malignancy. It may be used by general surgeons due to familiarity with anatomy of the relevant structures and lack of need for microsurgical skill.

CONCLUSION

The POSSG can be used in reconstruction of abdominal wall defects of any size by general surgeons.     

The indications and reliability of vein graft use in free flap transfer

BACKGROUND:

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES:

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS:

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS:

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION:

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.     

Free Boomerang-shaped Extended Rectus Abdominis Myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities

Background:

A soft tissue defect requiring flap cover which is longer than that provided by the conventional “long” free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free “Boomerang-shaped” Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and “free” version of a similar flap described by Ian Taylor in 1983.

Materials and Methods:

This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings.

Results:

Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line.

Conclusion:

BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.KEY WORDS: Extended rectus abdominis free flap, longest myocutaneous free flap, soft tissue reconstruction of extremities     

Management of scalp defects due to high-voltage electrical burns: a case series and proposed algorithm to treat calvarium injury

Background

Multiple modalities to manage scalp and underlying skull defect due to high-voltage electrical burns have been discussed. We aimed to describe our experience and to propose an algorithm for the management of skull injury which could be helpful in decision-making.

Methods

A retrospective study of patients who sustained electrical burns to the head from May 2007 to April 2012 was carried out. Sex, age, size of scalp defect, and method of reconstruction and management were analyzed.

Results

Thirteen patients were identified. Out of 13, 11 patients had scalp defects which were covered using local scalp flap. Free latissimus dorsi (LD) muscle flap and pedicle trapezius flap were used in two patients. The largest defect covered with local scalp flap was the size of 80 cm². Free LD flap was used to cover a defect of 144 cm². Of the nine patients who presented early (immediately after injury), seven required debridement of the outer table and the other two patients required full-thickness excision of the skull. The remaining four patients who presented late (after 3 months) were found to have osteomyelitic segments which required full thickness excision of the skull.

Conclusions

Most of the soft tissue defects of the scalp due to high-voltage electrical burns can be managed with local scalp flaps. However, if the local tissue is injured or not sufficient to close the defect, then free flap should be considered. In management of calvarium injury, the emphasis should be debridement of necrotic bone to provide infection-free site followed by soft tissue cover.Level of Evidence: Level IV, therapeutic study.

     

Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap

INTRODUCTION

Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors.

PRESENTATION OF CASE

The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18 cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted.

DISCUSSION

Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair.

CONCLUSION

The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.     

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.KEY WORDS: Distally based peroneal flaps, extended reverse sural flaps, foot reconstruction, peroneal artery, reverse peroneal flaps     

Lateral Calcaneal Artery Adipofascial Flap for Reconstruction of the Posterior Heel of the Foot

Background

Soft tissue defects of the posterior heel of the foot present difficult reconstructive problems. This paper reports the authors'' early experience of five patients treated with a lateral calcaneal artery adipofascial flap.

Methods

Between 2003 and 2007, five patients (3 males and 2 females) with soft-tissue defects over the posterior heel underwent a reconstruction using a lateral calcaneal artery adipofascial flap and a full-thickness skin graft. The flap sizes ranged from 3.5 × 2.5 cm to 5.5 × 4.0 cm.

Results

All five flaps survived completely with no subsequent breakdown of the grafted skin, even after regularly wearing normal shoes. The adipofascial flap donor sites were closed primarily in all patients.

Conclusions

Lateral calcaneal artery adipofascial flaps should be included in the surgical armamentarium to cover difficult wounds of the posterior heel of the foot. These flaps do not require the sacrifice of a major artery to the leg or foot, they are relatively thin with minimal morbidity at the donor site, and leave a simple linear scar over the lateral aspect of the foot.     

Multi-staged flap reconstruction for complex radiation thoracic ulcer

INTRODUCTION

Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach.

PRESENTATION OF CASE

The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224 cm², firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed.

DISCUSSION

This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs.

CONCLUSION

A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.     

Thoracodorsal artery perforator fasciocutaneous flap: A versatile alternative for coverage of various soft tissue defects

Objective:

The thoracodorsal artery perforator (TDAP) flap has contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous tissue. The optimal reconstruction method should provide thin, and well-vascularized tissue with minimal donor-site morbidity. The indications for the use of this particular flap with other flaps are discussed in this article.

Materials and Methods:

Thirteen patients underwent soft tissue reconstruction using TDAP flaps between 2009 and 2011. Of those, there were four cases of antecubital burn contracture, three cases of axillary burn contracture, two cases of giant hair cell nevus of upper extremity, two cases of axillary reconstruction following severe recurrent hidradenitis, and two cases of crush injury. All patients were male and their ages ranged from 20 to 23 (average, 21 years). The mean follow-up period was 8 months (range, 4-22 months).

Results:

All reconstructive procedures were completed without any major complications. Minor complications related to transfered flaps were wound dehiscence in one case, transient venous congestion in two cases. Minor complication related to the donor site was seroma in one case. The success rate was 100%, with satisfactory cosmetic results.

Conclusions:

The TDAP flap is a safe and extremely versatile flap that offers significant advantages in acute and delayed reconstruction. Although the vascular anatomy may be variable, free and pedicled TDAP flap is a versatile alternative for soft tissue defects. It adapts very well to the soft tissue defects with acceptable donor site scar.KEY WORDS: Burn contracture, hidradenitis suppurativa, soft tissue defects, the thoracodorsal artery perforator, thoracodorsal artery perforator flap     

Soft Tissue Reconstruction of the Foot Using the Distally Based Island Pedicle Flap after Resection of Malignant Melanoma

Background

We report on our experience with using a distally based island flap for soft tissue reconstruction of the foot in limb salvage surgery for malignant melanoma patients.

Methods

A distally based sural flap was used for 10 cases for the hindfoot reconstruction, and a lateral supramalleolar flap was used for 3 cases for the lateral arch reconstruction of the mid- and forefoot after wide excision of malignant melanomas.

Results

The length of the flap varied from 7.5 cm to 12 cm (mean, 9.6 cm) and the width varied from 6.5 cm to 12 cm (mean, 8.8 cm). Superficial necrosis developed in four flaps, but this was successfully treated by debridement and suture or a skin graft. All thirteen flaps survived completely and they provided good contour, stable and durable coverage for normal weight bearing.

Conclusions

The distally based sural flap is considered to be useful for reconstructing the hindfoot, and the lateral supramalleolar flap is good for reconstructing the lateral archs of the mid- and forefoot after resection of malignant melanoma of the foot.     

Arteriovenous fistulas for microvascular head and neck reconstruction

BACKGROUND:

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

METHODS:

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

RESULTS:

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

CONCLUSIONS:

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.     

The management of non-melanocytic skin malignancies of the scalp and calvarium

Background:

The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre.

Objective:

The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction.

Patients and Methods:

From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed.

Results:

Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients.

Conclusion:

These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.KEY WORDS: Bone invasion, calvarium, non-melanocytic, reconstruction, scalp, skin malignancies     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects     

Islandized mucoperiosteal flaps: A versatile technique for closure of a wide palatal cleft

BACKGROUND:

A variety of surgical methods have been described to repair wide cleft palate; they are all challenging to perform and yield consistently good results. The islandized mucoperiosteal flap, the technique described in the present article, is very versatile because it can close palatal defects of any size without undue tension. Moreover, it provides adequate length and mobility of the soft palate with improved speech and feeding functions without fistula formation.

METHODS:

Between 2005 and 2011, 36 patients with wide cleft palate were operated on using islandized mucoperiosteal flaps. This technique involves dissection of the neurovascular bundle from the mucoperiosteal flaps for approximately 1 cm and dissecting the muscle from the posterior edge of the hard palate with intravelar veloplasty. The flaps subsequently become freely mobile in all directions. It can move medially to close palatal defects of any size without tension. In addition, posterior or backward mobilization lengthens the soft palate and renders it freely mobile.

RESULTS:

All repairs were successful, with no complications and no patients requiring secondary procedures. All patients regained normal feeding function three weeks postoperatively. All patients showed normal nasal resonance of speech except for two (three and five years of age) who experienced abnormal resonance in the form of open nasality that required regular speech therapy for six months. There was significant improvement and no secondary procedures were required for either.

CONCLUSIONS:

A technical modification for closure of wide palatal clefts is introduced. The islandized mucoperiosteal flap, which is a very versatile technique, can close cleft palates of any width without tension, lengthens the soft palate and renders it freely mobile for proper speech functions. Using this technique, good speech and feeding function with no complications were achieved.