E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Background: Secondary palatal fistula and velopharyngeal insufficiency VPI are two major complications of palatoplasty. Various methods have been introduced for surgical repair of these complications; however, most of them are associated with a high recurrence rate and morbidity. This study was designed to evaluate the use of the buccinator myomucosal flap in the reconstruction of palatal fistula and velopharyngeal insufficiency following primary palatoplasty.
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Six anatomical dissections were performed on 3 fresh cadaver heads to investigate the neurovascular supply to the flap. There was 1 partial flap necrosis that occurred in a patient who had previously received radiation therapy and who healed secondarily without sequelae.
No patient experienced difficulties with mastication or oral competence. All patients reported light single-point touch sensation over the flap 2 weeks after surgery.
Cadaveric dissections using latex or india ink injections demonstrated the posterior neurovascular supply from the buccal artery, a branch of the internal maxillary artery, and the buccal nerve, a branch of the mandibular nerve. In the past, these flaps were used primarily for reconstruction of cleft palate defects.
The application of this flap to common defects of the posterior oral cavity after cancer resection has not been reported. The BMF provides sensate coverage for a variety of posterior oral cavity and oropharyngeal defects, and we have used it for reconstruction of defects involving the retromolar trigone, soft palate, and posterior floor of mouth.
We present this clinical experience and results of cadaveric dissections to demonstrate the anatomical basis and clinical applications of the BMF. The defect was allowed to heal secondarily. A BMF was raised intraorally and rotated on its posterior neurovascular pedicle into the defect. The flap was secured with slow absorbing sutures and the donor site was closed primarily. The patient was discharged home on postoperative day 1 on a soft solid diet.
The distal tip 3 mm of the flap underwent necrosis, but the resulting defect healed uneventfully by secondary intention after debridement. Light touch perception was demonstrated over the flap at the 2-week clinic follow-up. At 1 year of follow-up the patient was free of disease. On direct laryngoscopy the lesion was found to be superficially invasive, measuring 2 cm in diameter. This tumor was excised by an intraoral approach with 1-cm margins.
The patient was discharged on postoperative day 1 on a soft solid diet. Light touch perception was demonstrated over the flap at the 1-week clinic follow-up. He was free of disease 9 months later with no postoperative sequelae.
Eight patients were selected based on the defect anticipated after surgical excision. Seven of the patients were men and 1 was a woman, with an average age of 66 years. All patients were staged before excision as having a T1, N0, M0 or T2, N0, M0 squamous cell carcinoma SCC involving the soft palate 2 patients , retromolar trigone 5 patients , or floor of mouth 1 patient Table 1.
The smallest defect measured 2. Three patients had prior oral cavity carcinoma; 2 in the same site as the resection and 1 with a history of multiple small SCCs of the tongue previously excised before presenting with a separate palate lesion. All patients were followed up for a minimum of 1 year after surgery. Six anatomical dissections were performed on 3 fresh cadaver heads to develop a reliable technique of flap harvest and to investigate the vascular territory of the main posterior arterial feeder.
The vascular supply was defined by contrast injection: 1 cadaver was injected with india ink in the internal maxillary arteries and 2 were injected with latex in the carotid arteries and internal jugular veins. India ink was injected into the distal internal maxillary artery after ligating the branches between the point of injection and the buccal artery, thus allowing the ink to enter only the buccal artery.
A mL syringe with an gauge angiocatheter was inserted into the internal maxillary artery and secured with a crimping silk suture, and the ink was injected under steady continuous pressure for approximately 15 seconds. Dissections of the buccinator muscle and overlying mucosa were performed via an intraoral approach through a median mandibulotomy. Surgical technique The tumor is excised and the defect is sized Figure 1 and Figure 2.
Stensen duct is identified and the superior margin of the flap is outlined, keeping at least 3 mm inferior to the duct papilla Figure 3. The anterior limit of the flap is 1 cm behind the oral commissure. The maximal graft size possible is 4 cm in a superior-inferior direction and 7 cm in an anteroposterior direction. The buccal mucosa and the buccinator muscle are incised to the level of the buccopharyngeal fascia, working in an anterior to posterior direction.
A loose areolar plane exists between the buccinator muscle and the buccopharyngeal fascia, facilitating the elevation of the flap with blunt dissection. The buccopharyngeal fascia should be preserved for 2 reasons: to prevent buccal fat pad herniation into the field of dissection and to avoid injury to branches of the facial nerve.
Small branches from the facial artery may require ligation as may anterior venous tributaries from the pterygoid plexus.
The buccal artery, accompanying vein, and buccal nerve arise laterally at the posteroinferior aspect of the buccinator muscle. The pedicle may be isolated to create an island flap to facilitate rotation, but this is not usually necessary. The flap is then transferred into the defect and secured with long-lasting absorbable sutures, and the donor site is closed primarily Figure 4 and Figure 5.
Results Eight patients underwent primary tumor excision of soft palate, retromolar trigone, or floor of mouth lesions with the defect closed using the BMF. There were no tumor recurrences and no problems with mastication, oral continence, or facial nerve function.
All patients demonstrated touch perception over their flap 2 weeks after surgery. This was evaluated by light touch with a tongue depressor over the mucosa of the transposed flap.
There was 1 partial flap necrosis the distal 3 mm in case 1 that was allowed to heal secondarily without sequelae. The basic anatomy of this area has been described by Hollinshead 1 and others.
Buccinator flap as a method for palatal fistula and VPI management
Discussion Buccinator-based myomucosal flaps are not suitable for large oral mucosal defect coverage. Stensen duct pierce buccinator muscle slightly above its center. Considering 0. Partial buccinator flap is useful term for these flaps. Relocation of stensen duct adds more mucosa. Larger donor sites always managed with buccal fat pad mobilization, which undergoes epithelialization.
Six anatomical dissections were performed on 3 fresh cadaver heads to investigate the neurovascular supply to the flap. There was 1 partial flap necrosis that occurred in a patient who had previously received radiation therapy and who healed secondarily without sequelae. No patient experienced difficulties with mastication or oral competence. All patients reported light single-point touch sensation over the flap 2 weeks after surgery.
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