The uvulopalatal flap for reconstruction of the soft palate

OBJECTIVE: To determine the indications, complications, and outcomes of the uvulopalatal flap in the reconstruction of defects of the soft palate. STUDY DESIGN: Retrospective review. METHODS: Patient data were obtained from the hospital records of 18 patients who had soft palate defects reconstructed with the uvulopalatal flap over a 5-year period at a tertiary academic medical center. RESULTS: Eleven patients had the uvulopalatal flap as the sole method of reconstruction, whereas this flap was used in combination with a radial forearm free flap, pectoralis flap, and skin graft in 4, 2, and 1 patients, respectively. All flaps were successful in soft palate reconstruction. One flap was successfully revised after additional tumor resection. A partial flap dehiscence occurred in one patient and healed uneventfully. Speech and swallowing function was dependent on initial tumor stage and the scope of tumor resection. CONCLUSIONS: The uvulopalatal flap is a simple and effective method of soft palate reconstruction either alone or in combination with other methods of reconstruction for selected oropharyngeal defects.     

Surgical management of the hypodynamic palate.

The most successful surgical correction of velopharyngeal insufficiency (VPI) has been achieved in those patients in whom residual dynamic function of the soft palate/nasopharyngeal sphincter mechanism exists. In spite of the obvious need for rehabilitation, surgical reconstruction has often been advised against in those cases where the palate was hypodynamic or adynamic. We have developed a surgical procedure for these patients by utilizing a modification of Hogan's lateral port control pharyngeal flap method. We present the surgical considerations along with the initial application and results in four patients with hypodynamic palates of differing origins. We think that this technique extends surgical correction of VPI to the previously neglected group of patients in whom this condition is the result of a hypodynamic palate.     

Our experiences in microvascular reconstruction with free forearm skin flap

Free forearm skin-fascia flap was used at 14 patients for head and neck reconstruction. Tissue defect was located in mesopharynx at 6 patients, in piriformis recessus at 2, in buccal mucosa at 1, in hypopharynx 4 and very large defect embracing mesopharynx, hard and soft palate at one patient. To present moment lives 11 ill in this one from recurrent diseases. Most important element of microvascular junction is correctly executed venous junction. Patients after microvascular flaps showed less percentage of early complications (fistulas, shorter time of staging in Clinic). Connection of partial operation of the larynx with microvascular reconstruction of throat creates chance on good oncological on functional result. Free forearm skin-fascia flap provides good anatomical and functional result after various reconstructions of head and neck region.     

Functional outcomes following palatal reconstruction with a folded radial forearm free flap

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.     

One-stage reconstruction following resection of oropharyngeal carcinoma]

Fifty-nine cases undergone one-stage reconstruction following radical resection for oropharyngeal carcinoma were reviewed. Pectoralis major myocutaneous flap has been our first choice for reconstruction of surgical defects. A composite repair with forehead island flap and mucosal flap of the posterior pharyngeal wall for defect of the total soft palate was recommended. Preoperative radiation had some influence on wound healing. The 3 and 5 year survival rates were 58.1% and 41.7% respectively, and the cosmetic and functional restorations were satisfactory in most patients operated.     

The facial artery-buccinator musculo-mucosal flap for reconstruction of the palate

Since may 1999, 5 facial artery musculo-mucosal (FAMM) flaps have been used for mucosal reconstruction of the top of the mouth. The FAMM flap, first described by Pribaz in 1993 is a modification of the naso-labial cutaneous flap. The flap can be inferiorly based on the facial vessels (orthograde flow) or superiorly based (retrograde flow). It can easily reconstruct palate, alveolus and soft palate defects. The are of rotation has its pivot point inferiorly at the retromolar trigone, superiorly at the gingival labial sulcus. The FAMM flap has been used for 2 palatal fistula after facial blast injuries and 1 secondary cleft palate surgery. For the cleft palate surgery an Lefort 1 osteotomy with iliac crest graft was associated. All the flap but one survive with primary healing. One partial necrosis was noted but spontaneously healed secondarily. The FAMM flap is a reliable flap for mucosal reconstructions of the top of the mouth. The flap dissection is easy and the donor site morbidity is low.     

Nasopharyngeal pushback in treatment of velopharyngeal insufficiency.

We describe a new technique for extensive retropositioning of the soft palate for the treatment of velopharyngeal insufficiency. This technique is identified as a nasopharyngeal pushback, and has been used repeatedly in conjunction with both a Cronin nasal flap and a superiorly based pharyngeal flap when maximum retropositioning was needed. This procedure has been used for over ten years, each time obtaining an additional pushback distance equal to or greater than the distance achieved by freeling the soft palate from the posterior border of the hard palate.     

Reconstruction of the Soft Palate by Uvulopalatal Flap

Surgical removal of the soft palate in cases of neoplastic disease has a functionally detrimental effect on the patient, resulting in rhinolalia and nasal regurgitation. The authors describe their original surgical technique for repairing the lateral soft palate defect using a uvulopalatal flap. The flap is readily available and the procedure is single staged and without sequela. The aim of this reconstructive procedure is to obtain a diminished soft palate defect by primary surgery. In five patients who underwent a partial excision of the soft palate, the surgical defect was corrected at the time of initial surgery by a uvulopalatal flap. In this technique, the surface of the defect was diminished, postoperative rhinolalia and regurgitation were unremarkable, and sometimes an obturator was obviated. Using a local myomucosal flap, the procedure is simple, safe, and effective.     

Soft-palate reconstruction with a “SCARF” superior-constrictor advancement-rotation flap

Reconstruction of hemi-soft-palate defects after tumor resection is usually done by means of a regional flap, free-tissue transfer or a prosthesis. These options vary in complexity and have a number of shortcomings. A local myomucosal flap was designed that employs a superior-constrictor advancement-rotation flap (SCARF) to achieve circumferential closure of the velopharynx and to reestablish its valvular sphincteric function. Ten patients underwent a SCARF reconstruction of the velopharynx after 35% to 65% of the soft palate was resected. All patients reestablished normal velopharyngeal function without significant phonatory or deglutitive disability. Two patients did require a second-stage reinforcement of the suture line after partial dehiscence. The SCARF reconstruction of the soft palate is simple, fast, and reliable and there is no significant donor site morbidity. Patients resume oral intake earlier than standard reconstructive approaches. The SCARF can be done transorally, which allows for primary resection and discontinuous neck dissection. These factors facilitate short hospitalization and effective use of resources.     

Rekonstruktion im Oropharynx

Oropharyngeal cancer surgery often does not allow primary wound closure; furthermore, surgery of tumors in the base of the tongue, the soft palate and the lateral pharyngeal wall often lead to swallowing disorders and nasal twang which severely impair quality of life. Secondary scarring may also result in fixation of the tongue or stenosis of the pharynx. Therefor reconstructive techniques with free or pedicled flaps are essential to reduce functional impairment. In addition, after trauma or due to malformations, reconstructive surgery using flap techniques is sometimes indicated.     

The temporalis muscle flap for reconstruction after head and neck oncologic surgery.

OBJECTIVE: To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects. STUDY DESIGN: Fresh cadaver dissection and 5-year retrospective chart review. METHODS: A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base. RESULTS: Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing. CONCLUSIONS: Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.     

Functional repair of a major necrotic palatine defect caused by chronic cocaine inhalation

INTRODUCTION: Chronic use of cocaine provokes vasoconstriction and irritation of the upper airway epithelium. These mechanisms can lead to tissue necrosis and perforations. CASE REPORT: A 37-year-old woman had major centrofacial necrosis subsequent to chronic inhalation of cocaine. The tissue loss involved the right wing of the right ala nasi, the bony and soft palate and nearly all of the lateronasal walls. A microanastomosed antebrachial fasciocutaneous flap was used for reconstruction of the nasal vault. A classical veloplasty was used to close the palate. Velar competency was improved with a second procedure with Ortricochea sphincter pharyngoplasty. Later loss of the antebrachial flap required salvage with a flap from the lateral border of the tongue which provided a satisfactory functional result. DISCUSSION: This case of extended necrosis is rare and treatment was complex. Such treatment can only be undertaken after total and definitive cessation of drug abuse, including tobacco smoking.     

Pierre Robin sequence: postoperative complications following cleft palate surgery. A retrospective study covering 25 years]

BACKGROUND: In a 25-year retrospective review of 1976-2000, the postoperative course after cleft palate surgery and pharyngeal flap surgery in 87 children with Pierre Robin sequence was studied. PATIENTS AND METHODS: The study comprised 114 interventions with 87 primary palatoplasties; 17 patients required palatal fistulae repair and 10 children were treated with secondary pharyngoplasty procedures. All children were divided into three postnatal risk groups according to the severity of their symptoms at birth and in the course of the early months of life. RESULTS: A direct correlation was seen between the incidence of early postnatal difficulties and the postoperative obstructive complications after cleft palate surgery and pharyngeal flap surgery. Thus, children experiencing obstructive problems at birth (high postnatal risk group) displayed more severe complications at the time after cleft palate repair. In children undergoing pharyngeal flap surgery not only early postoperative obstruction but also late obstructive sleep apnea can occur.     

The palatal island flap for reconstruction of palatal and retromolar trigone defects revisited.

BACKGROUND: Although a host of local soft tissue flaps have been described for the reconstruction of postoperative palatal defects, tissue-borne palatal obturators remain the most common form of rehabilitation of these defects. The palatal island flap, first applied to the reconstruction of the retromolar trigone and palatal defects, was first described by Gullane and Arena in 1977. This single-staged mucoperiosteal flap offers a reliable source of regional vascularized soft tissue that obviates the need for prosthetic palatal rehabilitation. OBJECTIVE: To describe a series of 5 cases in which the palatal island flap was used as a primary palatal or retromolar reconstruction. METHODS: We have retrospectively reviewed 5 consecutive cases between March 1998 and August 1999 wherein palatal island flaps were used for the primary reconstruction of postablative palatal defects. Each case was reviewed for primary pathologic findings, postoperative wound complications, postoperative speech and swallowing, and donor site morbidity. Selection of this reconstructive technique was based on the size and location of the defect and the assessment by the surgeon that the arc of rotation and amount of residual palatal mucosa were appropriate. RESULTS: Six local palatal island flaps were performed on 5 patients who had not undergone irradiation (1 patient underwent bilateral flaps). The primary pathologic findings included T1 N0 squamous cell carcinoma, T4 N0 squamous cell carcinoma, T2 N0 low-grade mucoepidermoid carcinoma, pigmented neurofibroma, and T2 N0 low-grade clear cell carcinoma. All of the lesions were located on the hard or soft palate or the retromolar trigone, and the average defect size was 7.2 cm(2). All 5 patients began an oral diet between postoperative days 1 and 5 (mean, 2 days), and all patients were discharged home without postoperative donor site or recipient site complications between days 1 and 6 (mean, 3 days). Donor site reepithelialization was complete by 4 weeks in all 5 patients. CONCLUSIONS: The palatal island flap offers a reliable method of primary reconstruction for limited lesions of the retromolar trigone and hard and soft palate. The mucoperiosteal tissue associated with this flap is ideal for partitioning the oral and nasal cavities and obviates the need for prosthetic palatal obturation.     

Lipoinjection augmentation of the soft palate for velopharyngeal stress incompetence.

OBJECTIVES/HYPOTHESIS: Velopharyngeal stress incompetence in professional musicians is an uncommon but potentially career-ending problem. Pharyngeal flaps, V-Y palatal pushback procedures, Teflon or collagen injection of the posterior pharyngeal wall, and speech therapy have all been used to address this problem. The ideal procedure for this subset of patients with velopharyngeal incompetence (VPI) with high-pressure, mild VPI would be one that combines low morbidity and an expedient recovery for the busy musician. We describe an approach of endoscopically assisted autologous lipoinjection of the soft palate. STUDY DESIGN: A retrospective review of our experience treating high-pressure stress VPI in two professional musicians. METHODS: Literature review and retrospective chart review. RESULTS: Two musicians underwent autologous lipoinjection of the soft palate for stress VPI. Patients resumed full play within 2 weeks of the operation with no serious complications. There has been no recurrence of the VPI after 18 and 12 months of follow-up, respectively. CONCLUSIONS: Velopharyngeal stress incompetence in musicians is an uncommon disorder. Velopharyngeal incompetence in these patients may not present as in a typical manner with hypernasality but may go undiagnosed for years mistakenly rationalized as a declining performance ability rather than a curable structural problem. The performance demands of professional musicians necessitate a timely solution to their VPI. More precise and limited contouring of palatal bulk can be achieved through the lipoinjection technique than compared with traditional palatal V-Y pushback or a standard pharyngeal flap. Lipoinjection of the palate can be performed as an outpatient procedure with only minor discomfort and an expedient recovery for the career musician.     

Nasal Reconstruction Using a Combination of Alloplastic Materials and Autogenous Tissues: A Surgical Alternative

Re-creation of a functional and aesthetically acceptable nose after partial nasal defect requires accurate reproduction of nasal lining, support, and coverage. Most authors recommend an approach to reconstruction with cantilevered bone grafting and paramedian forehead flap placement. The authors propose an alternative approach for selected patients with total or near-total nasal defects combining both alloplastic and autogenous tissues. This method uses vitallium or titanium mesh for the dorsal framework formation, tissue-expanded paramedian forehead flap for soft tissue coverage, and composite chondrocutaneous auricular grafts for tip reconstruction. Nine individuals underwent nasal reconstruction using this method. The indications, details, and potential advantages of this technique are described with accompanying photographic results. A flexible approach using a combination of alloplastic materials and autogenous tissues provides additional reconstructive options for individuals with total or near-total nasal defects.     

The sternocleidomastoid myoperiosteal flap for esophagopharyngeal reconstruction and fistula repair: clinical and experimental study

Despite advances in head and neck surgery, reconstruction of the pharynx and cervical esophagus continues to be troublesome. Classic pedicled flaps are often too bulky and difficult to position for repair of pharyngeal and esophageal fistulas. An ideal flap would be local, well-vascularized, compact, and capable of being sutured into a tension-free, water-tight seal. In selected cases, the sternocleidomastoid myoperiosteal flap can meet these requirements in a single-stage procedure for repair of fistulas as well as selected cases of primary pharyngeal reconstruction. The use of this flap is described in five patients. Two patients underwent laryngectomy with partial pharyngectomy that left inadequate mucosa for primary closure. A sternocleidomastoid myoperiosteal flap was used to add width to the remaining mucosa. Both patients healed within 3 weeks and remained stricture free. Three other patients who underwent radiation followed by tumor resection and standard primary closure of the pharynx developed fistulas. Two fistulas were repaired successfully with the sternocleidomastoid myoperiosteal flap, and both patients were able to eat a general diet on the eighth postoperative day. Reconstruction was also performed in dogs to histologically evaluate the epithelialization capacity of the periosteum. There was total epithelialization of the flap at 4 weeks after reconstruction.     

Reconstruction of Pharyngeal Defects Using AlloDerm and Sternocleidomastoid Muscle Flap

Objective To report our experience in reconstructing pharyngeal defects that cannot be closed primarily, using acellular dermal matrix (AlloDerm, LifeCell Corp., Branchburg, NJ) and sternocleidomastoid (SCM) muscle flap. Study Design Prospective, nonrandomized, nonblinded study in the setting of an academic tertiary care medical center. Methods Fourteen patients underwent reconstruction of through‐and‐through defects of partial pharyngectomy for squamous cell carcinoma using AlloDerm graft. Primary closure of the defects was not possible because of substantial loss of pharyngeal tissue. The graft was reinforced with superiorly based SCM muscle flap in 10 patients. The remaining four patients did not receive any flap. Eleven lesions involved the lateral pharyngeal wall, and three were piriform sinus lesions. Patients were followed for a period ranging from 3 to 20 months. Outcome measures were determined on several parameters including graft take rate, evidence of graft contracture, postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist by means of a bedside swallowing examination. Five patients had videofluoroscopic studies. The three patients with piriform sinus lesions underwent videostroboscopic examination to assess vocal cord function. Results There was a high success rate for graft take. Two patients developed postoperative fistulas that resolved with conservative management . One of the 10 patients with SCM flap and one of the 4 patients without SCM flap developed fistulas. Clinically significant graft contracture or pharyngeal stenosis was not observed in any patients. All patients resumed oral intake. Ten patients resumed a normal diet, two tolerated a soft diet, and two could take purees. Decannulation was successful in all patients. Two of the three patients with piriform sinus lesions had vocal cord palsies after surgery resulting in breathy dysphonia. They underwent type I thyroplasty for vocal rehabilitation. All patients had intelligible speech. Conclusions Thick AlloDerm, reinforced with SCM muscle or cervical soft tissue, provides a useful alternative option for reconstruction of pharyngeal defects that cannot be closed primarily. It is safe and effective and provides excellent functional outcomes.     

Lateral upper arm free flap for primary reconstruction of pharyngeal defects in ablative oncological surgery. Report of six consecutive cases

Free microvascular flaps are an established method for soft tissue reconstruction following ablative oncological surgery in the head and neck. Functional reconstructions of the hypopharynx and the pharyngoesophageal segment (PES) are of particular relevance, as they are highly demanding surgical procedures. So far, the radial forearm free flap (RFFF) and the free jejunal transfer have been the transplants predominantly used for this purpose. The lateral upper arm free flap (LUFF) presents an alternative method for the fasciocutaneous tissue transfer. We report on our experience with the LUFF in a 56-year-old male patient with a pT3pN0M0 squamous cell carcinoma of the hypopharynx. A pharyngocutaneous fistula developed 5 days after pharyngolaryngectomy with bilateral neck dissection. The fistula was localized between the pharyngeal constrictor muscle and the esophagus and was closed with an LUFF from the left arm. Excellent flap adaptation to the remaining pharyngeal mucosa was observed. Although the length of the vascular pedicle and the diameter of the vessels in the LUFF are smaller than those in the RFFF, neither pedicle length nor vessel diameter proved to be a problem. The LUFF can be recommended as a well-vascularized, relatively safe and reliable flap for reconstruction of tubular structures such as the hypopharynx and the PES after tumor ablation and as an alternative to the RFFF. The flexibility of the LUFF allows surgeons to reconstruct the anatomy of the lost soft tissues as adequately as possible.