Primary reconstruction of palatal defects

Removal of the soft palate can cause marked functional deficit in deglutition and phonation. Most commonly, treatment of this deformity with prosthetic obturation has been less than ideal. Numerous reconstructive techniques have met with only partial success, while deforming distant structures. We will present a technique of reconstruction of the soft palate by use of a superiorly based pharyngeal flap. It has been used successfully in five patients who underwent soft palatectomy for malignant disease. The flaps have been the full width of the pharynx and extended down to the esophageal inlet. Viability of the flap is excellent, and the donor site is allowed to heal by secondary intention. Excellent function has been achieved in all cases with no compromise of oncological principles.     

Large tongue flaps to close massive palatal defects

Ten patients with large palatal fistulae due to various etiologies are presented. The surgical technique used to close these defects and the perioperative management are both discussed. Closure was successful in all but one. Two patients had small fistulae which required minor repairs. Two patients had bone grafts which were inserted through the flap at a second stage, with subsequent placement of osseointegrated dental implants. Received: 4 February 1999 / Accepted: 25 February 1999     

Immediate microvascular reconstruction of combined palatal and midfacial defects

We describe a method for immediate one-stage reconstruction of combined palatal and midfacial defects using latissimus dorsi musculocutaneous free-tissue transfer. It has consistently provided healed wounds, restoration of palatal function, and preservation of facial contour while obviating the need for a palatal prosthesis. This reconstructive method, which uses only autogenous tissue, may offer a significant advantage in cases where more than a hemimaxillectomy is required, for compound defects resulting from the sacrifice of facial structures along with the maxillectomy, and in situations where the resection involves cranial base structures with a resultant need to separate the cranial contents from the oral and nasal cavities. Finally, it provides an alternative to prosthetic rehabilitation for the elderly patient with decreased or absent vision.     

Reconstruction of large palatal defects using the free anterolateral thigh flap

The ideal reconstructive method for the palatal defect should provide durable, stable coverage, and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Although small and usual palatal defects can be repaired easily using local adjacent tissues, successful closure of large, complex defects is still a challenging problem. Numerous free tissue options have to date been described for large palatal defects. Although the radial forearm flap constitutes a good option for ideal reconstructive goals, the sacrifice of a major artery to the hand and the skin graft to the forearm with its high potential risk of complications are evident problems attendant upon this donor site. Since the first report of the anterolateral thigh flap, this has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. Between April 2005 and May 2009, 8 free anterolateral thigh flaps were used to reconstruct defects of the palate. The study involved 6 male and 2 female patients, their ages ranging from 3 to 45. Five patients had palatal defects due to congenital cleft palate deformity, 2 patients had defects due to tumor resection, and the remaining patient had a palatal defect due to a gunshot wound. The size of the flaps ranged from 8 to 14 cm in length and from 4 to 7 cm in width. Facial vessels were used as recipient vascular sources in all patients. Primary thinning of the flap was performed in all cases. Donor sites were closed directly and healed uneventfully in all patients. There were no postoperative complications and all flaps survived totally. No debulking was needed. All patients, and their families in the case of child patients, were satisfied with the results of their surgical treatment. In conclusion, although it has some irregularity in derivation from the main vessels, with its evident structural and cosmetic advantages the anterolateral thigh flap can be considered an excellent and ideal free flap option for most large palatal defects that cannot be closed by regional tissue in selected patients. It can reconstruct defects in single stage with well-vascularized tissue, resulting in minimal donor site morbidity.     

Reconstruction of maxillary and palatal defects with the free radial forearm flap

We present six patients with maxillary and palate defects that were reconstructed with the radial forearm flap. Four patients had malignant neoplasms involving the maxilla, three with squamous cell carcinoma and the fourth with recurrent basal cell carcinoma. They were treated with excision and immediate reconstruction using a radial forearm free flap. The other two patients presented with large fistulae between the maxilla and nasal sinuses, these being sequelae of previous surgical treatment for malignancies. The fistulae were closed with radial forearm free flaps. This method provides primary wound healing, restoration of palatal function, preservation of facial contour, and a minimal morbidity while obviating the need for palatal prosthesis. In the six cases, the oral cavity has been completely separated from the paranasal sinus and nasal cavity, and all patients demonstrated satisfactory deglutition and intelligible speech.     

Simulated nasoalveolar palatal defects: a canine model to study bone grafts

A simple, surgical technique to create a simulated nasoalveolar palatal defect in the canine is described. The procedure has been performed in 60 canines, and we have not experienced closure of the created clefts. The surgically created clefts had to fulfill five criteria: (1) bilateral maxillary alveolar clefts had to exist in each research animal; (2) each cleft had to have a 1-cm bony width; (3) a demonstrable oronasal communication had to be present; (4) each cleft had to be lined by healthy epithelialized mucosa; (5) there had to be functional teeth adjacent to each side of every cleft.     

The use of split metatarsal osteocutaneous free flaps in palatal and alveolar defects

A series of seven osteomucosal defects of the palate were closed by split metatarsal osteocutaneous free flaps. All seven patients had successful closure of their defects with minimal facial scarring and insignificant donor site morbidity. This procedure, performed in one stage, avoids the use of previously compromised local tissues and improves the blood supply to the area, thereby enhancing the subsequent indicated reconstruction of other damaged structures.     

Immediate microvascular reconstruction of combined palatal and midfacial defects using soft tissue only

Maxillary and midface defects with or without orbital involvement are disfiguring and disabling problems especially in the elderly cancer patient. Often, palatal prostheses are required to enable speech and swallowing. Elderly patients or those with compromised vision often find these appliances cumbersome and difficult to manage. To help obviate these problems a one-stage method of immediate palatal reconstruction was needed to obturate the palate and restore facial contour. Over the past 18 months six patients have undergone immediate reconstruction of complex, composite defects of the maxillary and midface structures after tumor extirpation, three of which extended into the orbit. The latissimus dorsi musculocutaneous flap was utilized because of its bulk, reliable anatomy, ample pedicle length and diameter, and minimal donor site morbidity. No flap loss, suture line dehiscence, or infection occurred. All patients were capable of deglutition and intelligible speech. This technique is a one-stage reconstruction of the palate and accompanying defects of the midface and maxilla that obviates the need for cumbersome palatal appliances.     

出生结构异常的产前诊断

严重出生结构异常是危害新生儿生命和健康的重要出生缺陷性疾病群之一.据美国March of Dimes出生缺陷基金会2006年估计,全世界每年大约有250万因遗传或由于环境因素所致的严重结构异常,占出生人口总数的2%.我国每年约有80～120万先天残疾儿童出生,并且有不断上升的趋势.普及产前筛查、提高产前诊断率,有利于先天性结构异常的早期诊断和治疗,产前诊断即给小儿外科医师带来胎儿或新生儿早期干预治疗的机遇;但与此同时,也带来了挑战.     

The thoracodorsal artery perforator-scapular osteocutaneous (TDAP-SOC) flap for reconstruction of palatal and maxillary defects

Despite technical advances over the past 3 decades, subtotal, total, and extended total maxillectomy defects remain challenging reconstructive problems. In particular, postoncologic resection of the maxilla results in complex 3-dimensional defects of the midface, which cause severe functional and esthetic deformities. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and maxilla is especially challenging because it requires reconstitution of the facial buttresses, occlusion, replacement of bony hard palate, and the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue-bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. Osteocutaneous and osteomuscular flaps such originating from the scapular, iliac, peroneal, and radial vascular systems have been attempted with good success.We devised an osteocutaneous flap based on the scapular vascular system, which provided bone and soft tissue to successfully reconstruct the palate and maxilla in 2 patients. The skin paddle received its blood supply from the major perforating vessels of the thoracodorsal artery, and the scapular bone was nourished by the angular vessels. Although free tissue transfer using thoracodorsal perforator flaps has been described, this flap has not been previously reported in the literature as an osteocutaneous tissue transfer. With the use of rigid fixation, excellent results have been obtained with this technique for palatal and maxillary reconstruction.     

Impact of palatal prosthodontic intervention on communication performance of patients' maxillectomy defects: a multilevel outcome study

BACKGROUND: Obturators have been developed for surgical defects caused by cancer of the maxillary sinus and alveolar ridge. Outcome research is necessary to develop evidence-based practice guidelines. METHODS: Thirty-two consecutively treated maxillectomy patients seen in the Facial Prosthetics Clinic at UNMC from 1994 through 1996 had their defects obturated for 1 month when speech intelligibility, speaking rate, nasality, and communication effectiveness were measured. RESULTS: With the obturator removed, mean speech intelligibility was 61%, speaking rate was 138 words per minute, and nasality was rated as 5.8 on a 0-7 point scale. With the obturator inserted, mean speech intelligibility was 94%, speaking rate was 164 words per minute, and nasality was rated as 1.6. The mean self-perception of communication effectiveness was 75% of what it was before the diagnosis of cancer. CONCLUSIONS: Obturation is an effective intervention for defects of the maxillary sinus and alveolar ridge on speech performance. Variations in effectiveness were noted based on site of defect and patient satisfaction with the intervention.