HEAD
AND
NECK SURGERY
Reconstruction of the Dynamic Velopharyngeal Function by Combined Radial ForearmYPalmaris Longus Tenocutaneous Free Flap, and Superiorly Based Pharyngeal Flap in Postoncologic Total Palatal Defect Takashi Nuri, MD, PhD, Koichi Ueda, MD, PhD, Akira Yamada, MD, PhD, Masashi Okada, MD, PhD, and Mai Hara, MD Abstract: We attempted to reconstruct dynamic palatal function using a radial forearmYpalmaris longus tenocutaneous free flap in conjunction with a pharyngeal flap for a postoncologic total-palate defect in a 67-year-old male patient. This reconstruction involved 3 important tasks, namely, separating the oral and nasal cavities, preserving the velopharyngeal space to avoid sleep apnea, and maintaining velopharyngeal closure to avoid nasal regurgitation during swallowing. In our technique, the radial forearm flap separates the oral and nasal cavities with an open rhinopharyngeal space, and a superiorly based pharyngeal flap, which is sutured to the posterior end of the forearm flap, limits the rhinopharyngeal space, and forms the bilateral velopharyngeal port. Furthermore, the palmaris longus tendon, which is attached to the forearm flap, is secured to the superior constrictor muscle to create a horizontal muscle sling. Contraction of the superior constrictor muscle leads to shrinkage of the sling, resulting in velopharyngeal closure. Swallowing therapy was started 4 weeks after the surgery. The patient could resume oral intake without any difficulties 6 months after the surgery. Speech intelligibility changed from severe to minimal hypernasality. Key Words: palatal defect, head and neck reconstruction, radial forearm free flap, palmaris longus tendon, reconstruct the function, velopharyngeal incompetence, pharyngeal flap
radial forearmYpalmaris longus tenocutaneous free flap. In their technique, the palmaris longus tendon was connected between the remnant muscle of the lateral pharyngeal constrictor muscle and the remaining free margin of the levator veli palatini muscle. The reconstructed ‘‘muscle sling’’ is expected to work as a physiologically normal muscle. However, the functional outcome depends on the amount of remnant oropharyngeal and palatal musculature after cancer resection. Roh et al6 and McCombe et al7 reported that patients who had undergone resection of a large part of the palate failed to exhibit velopharyngeal closure on phonation. These results show that after wide resection including the levator veli palatine muscle, reconstruction of the physiologic velopharyngeal closure mechanism is impossible. There are no reports on reconstruction of total-palate defects with satisfying velopharyngeal function. We applied a radial forearmYpalmaris longus tenocutaneous free flap with functional movement in conjunction with a superiorly based pharyngeal flap for treatment of a full-palate defect. This technique allowed for restoration of velopharyngeal function. The purpose of this article was to introduce our new concept of functional palate reconstruction.
(Ann Plast Surg 2015;74: 437Y441)
PATIENT AND METHODS Patient
W
ide resection of oropharyngeal cancer involving the soft palate can cause velopharyngeal incompetence, which leads to disturbed speech characterized by hypernasality and difficulty in swallowing because of nasal regurgitation. Therefore, the reconstructive surgeon must consider not only covering the defect but also providing velopharyngeal function. Several flaps have been used for reconstruction of the palate.1Y5 More recently, the radial forearm free flap has been used for reconstruction of the palate. In the normal movement of velopharyngeal closure, contraction of the pharyngeal wall, elevation and elongation of the soft palate, and anterior excursion of the posterior pharyngeal wall can be observed. Among these structures, the soft palate is known to play a crucial role in velopharyngeal closure. This movement is achieved by contraction of 3 muscles; among them, the levator veli palatini muscle plays the most important role in elongation and elevation. Roh et al6 described the repair of a moderately sized postoncologic soft palate defect using a
Received November 6, 2012, and accepted for publication, after revision, July 19, 2013. From the Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Takashi Nuri, MD, PhD, Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404-0437 DOI: 10.1097/SAP.0b013e3182a63618
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
A 67-year-old man had a myoepithelial carcinoma of the soft palate. He underwent resection of the soft and hard palate (Fig. 1) followed by 60-Gy radiation therapy. After the treatment, he could not eat or drink because of regurgitation and aspiration. He was fed only through a gastrostomy tube. To prevent aspiration, he underwent a tracheotomy. The levator veli palatini and the 2 other muscles that form the levator muscle sling were resected with the tumor. Preoperative examination of the lateral pharyngeal motion showed no limitation of the lateral pharyngeal wall motion.
Surgical Technique The operation was performed in 2 steps. A radial forearmY palmaris longus tenocutaneous flap was designed on the distal forearm to correspond with the defect, and the ulnar end of the flap, which was to become the posterior end of the palate, was designed to be concave. During the first operation, half of the f lap was raised, the proximal and distal ends of the palmaris longus tendon were cut, and the distal end was displaced distally to obtain a sufficient length. The 2 pieces of the oral mucosal grafts were grafted onto the palmaris longus tendon (Fig. 2). The flap was again secured to the donor. Three weeks after this prefabrication, the radial forearm flap was raised completely with the palmaris longus tendon. After the radial forearm free f lap transfer, the radial artery and concomitant vein were anastomosed to the facial artery and external jugular vein, and the radial forearm flap was sutured to the defect with an open rhinopharynx. After the bilateral incision of the lateral pharyngeal wall, both ends of the palmaris longus tendon were secured to the bilateral superior constrictor muscles. Finally, the superiorly based pharyngeal flap with www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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& Volume 74, Number 4, April 2015
FIGURE 1. CT demonstrates hard and soft palate defect (above). After resection of the palate, nasal cavity can be seen from the mouth.
FIGURE 2. Image of the prefabrication. Above left, The radial forearm f lap was designed to correspond with the defect, and the ulnar side of the f lap was designed to be concave. Below left, Half of the f lap was raised, and the palmaris longus tendon was displaced distally. Above right, Two pieces of the oral mucosa were grafted onto the palmaris longus tendon. The space between the 2 mucosal grafts is necessary for the pharyngeal f lap, which will be sutured with forearm f lap. 438
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Reconstruction of Velopharyngeal Function
FIGURE 3. Above left, The design of the superiorly based pharyngeal flap and incision to identify the superior constrictor muscle (arrows). Above right, The flap has sufficient vessel and palmaris longus tendon length on both sides. Below, The oral mucosal grafts had completely survived on the palmaris longus tendon. Below right, The radial forearm flap was sutured into the mouth. Both ends of the flap (originally the ulnar side of the flap) were sutured to the lateral pharyngeal wall. Furthermore, the palmaris longus tendon was secured to the constrictor muscle (double arrow), and the pharyngeal flap was sutured to the middle of the posterior margin of the forearm flap.
half the width of the posterior pharyngeal wall was raised and secured to the posterior margin of the forearm flap between the 2 oral mucosal grafts (Fig. 3).
RESULTS There were no wound-related or microsurgical complications. Nasoendoscopic examination performed 2 weeks after the operation revealed the existence of bilateral velopharyngeal port and lateral pharyngeal wall movement. We started swallowing therapy 4 weeks after the surgery. Videofluoroscopic examination 14 weeks after the surgery showed that the patient could intake both liquid and thickened diets without any regurgitation or aspiration. Twelve weeks after the operation, the patient could resume oral intake without any difficulties (Fig. 4). Finally, 6 months postoperatively, the gastrostomy tube and tracheotomy could be removed. Currently, the patient has no sleep apnea, and his speech intelligibility has changed from severe to minimal hypernasality (see Video, Supplemental Digital Content 1, http://links.lww.com/SPA/A78, which demonstrates the videofluoroscopic examination and speech).
DISCUSSION Disruption of valvular function of the soft palate leads to disturbed speech and difficulty in swallowing. Reconstruction of the palate should not only cover the defect but also provide velopharyngeal function. Reconstruction after ablation surgery for oropharyngeal cancer involving the soft palate is always challenging for head and neck reconstructive surgeons. To reconstruct the velopharyngeal function after full-palate resection, it is necessary to undertake 3 tasks. The first task is to cover the large palatal defect and separate the nasal cavity from the * 2015 Wolters Kluwer Health, Inc. All rights reserved.
oral cavity to prevent speech difficulty such as hypernasal speech. However, complete occlusion of nasopharyngeal space leads to respiratory disturbance. Therefore, the second task is to maintain the rhinopharyngeal space to prevent sleep apnea, and the third is to close the rhinopharyngeal space during swallowing to prevent nasal regurgitation of food. The conventional solution to cover the palatal defect has been to obturate this area with a palatal prosthesis. However, placement of a palatal prosthesis has several disadvantages, including discomfort, malodor, persistent velopharyngeal insufficiency (particularly in patients with large defects), elimination of sensory feedback from the intact mucosa, and social awkwardness inherent in having a large oral prosthesis.8 To circumvent these problems, several f laps have been used for reconstruction of the palate.1Y5 Recently, the radial forearm free f lap has been commonly used for reconstruction of the palate6Y9 because the skin is thin, pliable, abundant, and well vascularized, which allows for considerable freedom in f lap design. To obtain valvular function of the reconstructed palate, some reconstructive techniques using the radial forearmYpalmaris longus tenocutaneous free f lap have recently been reported. McCombe et al7 reported use of the radial forearmYpalmaris longus tenocutaneous free f lap for reconstruction of defect comprising 50% to 100% of the soft palate. In their technique, tendons were sutured to the oropharyngeal musculature as far, posteriorly and superiorly, as possible to elevate the posterior margin of the palate. However, palate motion was very limited or absent in patients with defects of greater than 75% of the palate. In 2009, Roh et al6 tried to reconstruct moderately sized defects (from small defects to large postoncologic defects involving more than three fourths of the soft palate) by using the forearmYpalmaris longus tenocutaneous free flap. In their report, the www.annalsplasticsurgery.com
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Annals of Plastic Surgery
Nuri et al
FIGURE 4. Nasoendoscopic view and videofluoroscopy 14 weeks after the surgery. Above, Postoperative view. Below, Nasoendoscopic view shows the pharyngeal flap (middle) and bilateral velopharyngeal port (arrows). Right, Videofluoroscopic image shows no regurgitation or aspiration.
& Volume 74, Number 4, April 2015
palmaris longus tendons were connected between the remnant muscles of the lateral pharyngeal constrictor muscle and the remaining free margin of the levator veli palatini muscle on the contralateral side. Such concept to reconstruct the valvular function of the soft palate by using the remnant levator muscle is ideal. However, the functional outcome depends on the amount of remnant oropharyngeal and palatal musculature after cancer resection. Roh et al reported that patients who had undergone resection of more than three fourths of the palate failed to exhibit velopharyngeal closure on phonation. The pharyngeal f lap has been considered to be the workhorse f lap in treating congenital velopharyngeal insufficiency. The purpose of the pharyngeal f lap procedure is to enable velopharyngeal closure for speech and swallowing without causing obstruction of the nasal airway. Brown et al9 reconstructed palate defects using a radial forearm flap in conjunction with a superiorly based pharyngeal f lap. In their report, the additional pharyngeal flap showed a speech advantage. However, in the subjective assessment of swallowing, the additional pharyngeal flap group did not show an obvious advantage. Static palatal reconstruction using a forearm flap with a pharyngeal f lap can limit the airway but cannot prevent regurgitation of the diet. The width of the pharyngeal flap should be determined by considering the lateral pharyngeal wall motion. Sullivan et al10 suggested that preoperative videofluoroscopic studies are important to determine the extent of lateral pharyngeal movement. Shapiro et al11 created a resting velopharyngeal port that measured at least 20 mm2 to assist in normal speech production after reconstruction of soft palate defects with a superiorly based pharyngeal flap. Hogan and Schwartz12 recommended that the lateral port should be no larger than 20 mm2 to prevent velopharyngeal insufficiency during reconstruction of the soft palate in the treatment of cleft palate and other congenital defects. However, there are no standards for adult patients who have undergone palate resection. We decided that the width of the pharyngeal f lap would be 50% of the width of the pharynx because the lateral pharyngeal wall motion was normal. The velopharyngeal ports were larger than 20 mm2 as a result. To avoid nasal regurgitation during swallowing, reconstruction of dynamic velopharyngeal function is needed. In the normal velopharyngeal closure movement, contraction of the pharyngeal wall, elevation and elongation of the soft palate, and anterior excursion of the posterior pharyngeal wall can be observed. In our case, the levator veli muscle was fully resected with the tumor; therefore, we attempted to secure the palmaris longus tendon to the superior constrictor muscle. We speculated that the superior constrictor muscle and palmaris longus tendon would create a horizontal muscle sling. Contraction of the superior constrictor muscle tows the palmaris longus tendon, which leads to closure of the velopharyngeal port (Fig. 5). Furthermore, the palmaris longus tendon
FIGURE 5. Schematic illustration of reconstructed velopharyngeal function. Superior constrictor muscle and palmaris longus tendon form the horizontal muscle sling, and contraction of the superior constrictor muscle affects shrinkage of the sling. 440
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
& Volume 74, Number 4, April 2015
Reconstruction of Velopharyngeal Function
might play a role in preventing contraction of the forearm flap. The palmaris longus tendon has proven to be useful in various postoncologic reconstructions in the head and neck area13,14; however, the tendon is not vascularized, and surgeons must therefore take care to prevent infection. To avoid exposure of the palmaris longus tendon to the nasal cavity, we grafted the oral mucosa onto the palmaris longus tendon during the first operation. The nonepithelialized side of the radial forearm causes contraction of the flap, resulting in the flap being drawn away from the posterior pharyngeal wall. Brown et al9 suggested that a superiorly pharyngeal flap sutured to the nonepithelialized side of the radial forearm flap would reduce contraction of the radial forearm flap. In our technique, the operation is performed in 2 steps: mucosal grafting reduces the nonepithelialized area of the radial forearm flap, which reduces the contraction of the forearm flap. Furthermore, during the first operation, the position of the palmaris longus tendon can be shifted distally to gain sufficient length for formation of the sling. Microsurgical reconstructive techniques have revolutionized postablative reconstruction of the head and neck. However, there is a limit to reconstruction of the dynamic function of the palate solely by the free flap technique. Our technique is a combination of the latest technique using the radial forearmYpalmaris longus tenocutaneous free f lap and the traditional method of treating velopharyngeal insufficiency. As the videofluoroscopic and speech study results show, the present patient obtained normal swallowing function, and speech intelligibility changed from severe to minimal hypernasality. These results show that our technique can be one of the best reconstructive choices for full-palate defects, although further studies are important to substantiate these results.
2. Thomson CJ, Allison RS. The temporalis muscle flap in intraoral reconstruction. Aust N Z J Surg. 1977;67:878Y882. 3. Hanasono MM, Utley DS, Goode RL. The temporalis muscle flap for reconstruction after head and neck oncologic surgery. Laryngoscope. 2001;111: 1719Y1725. 4. Genden EM, Lee BB, Urken ML. The palatal island flap for reconstruction of palatal and retromolar trigone defect revisited. Arch Otolaryngol Head Neck Surg. 2001;127:837Y841. 5. Moore BA, Magdy E, Netterville JL, et al. Palatal reconstruction with the palatal island flap. Laryngoscope. 2003;113:946Y951. 6. Roh TS, Lee WJ, Choi EC, et al. Radial forearmYpalmaris longus tenocutaneous free flap; implication in the repair of the moderate-sized postoncologic soft palate defect. Head Neck. 2009;31:1220Y1227. 7. McCombe D, Lyons B, Winkler R, et al. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg. 2005;58:306Y311. 8. Lacombe V, Blackwell KE. Radial forearm free flap for soft palate reconstruction. Arch Facial Plast Surg. 1999;1:130Y132. 9. Brown JS, Zuydam AC, Jones DC, et al. Functional outcome in soft palate reconstruction using radial forearm free flap in conjunction with a superiorly based pharyngeal flap. Head Neck. 1997;19:524Y534. 10. Sullivan SR, Marrinan EM, Mulliken JB. Pharyngeal flap outcome in nonsyndromic children with repaired cleft palate and velopharyngeal insufficiency. Plast Reconstr Surg. 2010;125:290Y298. 11. Shapiro BM, Komisar A, Silver C, et al. Primary reconstruction of palate defect. Otolaryngol Head Neck Surg. 1986;95:581Y585. 12. Hogan VM, Schwartz MF. Velopharyngeal incompetence. In: Converse JM, ed. Reconstructive Plastic Surgery: Principles and Procedure in Correction, Reconstruction, and Transplantation. 2nd ed. Vol. 4. Philadelphia, Pa: W.B. Saunders; 1977:2268Y2295. 13. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearmYpalmaris longus free flap. Plast Reconstr Surg. 1991;88:209Y214. 14. Chantrain G, Deraemaecker R. Glottic reconstruction after cricohyoidoepiglottopexy with a radial forearm free flap that includes the tendon of the palmaris longus: preliminary results and perspectives. Laryngoscope. 1994;104:1035Y1040.
Annals of Plastic Surgery
REFERENCES 1. Zoller J, Maiser H. Intraoral cheek transposition flap for primary reconstruction of the soft palate. Int J Oral Maxillofac Surg. 1992;21:156Y159.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.annalsplasticsurgery.com
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441
AND
NECK SURGERY
Reconstruction of the Dynamic Velopharyngeal Function by Combined Radial ForearmYPalmaris Longus Tenocutaneous Free Flap, and Superiorly Based Pharyngeal Flap in Postoncologic Total Palatal Defect Takashi Nuri, MD, PhD, Koichi Ueda, MD, PhD, Akira Yamada, MD, PhD, Masashi Okada, MD, PhD, and Mai Hara, MD Abstract: We attempted to reconstruct dynamic palatal function using a radial forearmYpalmaris longus tenocutaneous free flap in conjunction with a pharyngeal flap for a postoncologic total-palate defect in a 67-year-old male patient. This reconstruction involved 3 important tasks, namely, separating the oral and nasal cavities, preserving the velopharyngeal space to avoid sleep apnea, and maintaining velopharyngeal closure to avoid nasal regurgitation during swallowing. In our technique, the radial forearm flap separates the oral and nasal cavities with an open rhinopharyngeal space, and a superiorly based pharyngeal flap, which is sutured to the posterior end of the forearm flap, limits the rhinopharyngeal space, and forms the bilateral velopharyngeal port. Furthermore, the palmaris longus tendon, which is attached to the forearm flap, is secured to the superior constrictor muscle to create a horizontal muscle sling. Contraction of the superior constrictor muscle leads to shrinkage of the sling, resulting in velopharyngeal closure. Swallowing therapy was started 4 weeks after the surgery. The patient could resume oral intake without any difficulties 6 months after the surgery. Speech intelligibility changed from severe to minimal hypernasality. Key Words: palatal defect, head and neck reconstruction, radial forearm free flap, palmaris longus tendon, reconstruct the function, velopharyngeal incompetence, pharyngeal flap
radial forearmYpalmaris longus tenocutaneous free flap. In their technique, the palmaris longus tendon was connected between the remnant muscle of the lateral pharyngeal constrictor muscle and the remaining free margin of the levator veli palatini muscle. The reconstructed ‘‘muscle sling’’ is expected to work as a physiologically normal muscle. However, the functional outcome depends on the amount of remnant oropharyngeal and palatal musculature after cancer resection. Roh et al6 and McCombe et al7 reported that patients who had undergone resection of a large part of the palate failed to exhibit velopharyngeal closure on phonation. These results show that after wide resection including the levator veli palatine muscle, reconstruction of the physiologic velopharyngeal closure mechanism is impossible. There are no reports on reconstruction of total-palate defects with satisfying velopharyngeal function. We applied a radial forearmYpalmaris longus tenocutaneous free flap with functional movement in conjunction with a superiorly based pharyngeal flap for treatment of a full-palate defect. This technique allowed for restoration of velopharyngeal function. The purpose of this article was to introduce our new concept of functional palate reconstruction.
(Ann Plast Surg 2015;74: 437Y441)
PATIENT AND METHODS Patient
W
ide resection of oropharyngeal cancer involving the soft palate can cause velopharyngeal incompetence, which leads to disturbed speech characterized by hypernasality and difficulty in swallowing because of nasal regurgitation. Therefore, the reconstructive surgeon must consider not only covering the defect but also providing velopharyngeal function. Several flaps have been used for reconstruction of the palate.1Y5 More recently, the radial forearm free flap has been used for reconstruction of the palate. In the normal movement of velopharyngeal closure, contraction of the pharyngeal wall, elevation and elongation of the soft palate, and anterior excursion of the posterior pharyngeal wall can be observed. Among these structures, the soft palate is known to play a crucial role in velopharyngeal closure. This movement is achieved by contraction of 3 muscles; among them, the levator veli palatini muscle plays the most important role in elongation and elevation. Roh et al6 described the repair of a moderately sized postoncologic soft palate defect using a
Received November 6, 2012, and accepted for publication, after revision, July 19, 2013. From the Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Takashi Nuri, MD, PhD, Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7404-0437 DOI: 10.1097/SAP.0b013e3182a63618
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
A 67-year-old man had a myoepithelial carcinoma of the soft palate. He underwent resection of the soft and hard palate (Fig. 1) followed by 60-Gy radiation therapy. After the treatment, he could not eat or drink because of regurgitation and aspiration. He was fed only through a gastrostomy tube. To prevent aspiration, he underwent a tracheotomy. The levator veli palatini and the 2 other muscles that form the levator muscle sling were resected with the tumor. Preoperative examination of the lateral pharyngeal motion showed no limitation of the lateral pharyngeal wall motion.
Surgical Technique The operation was performed in 2 steps. A radial forearmY palmaris longus tenocutaneous flap was designed on the distal forearm to correspond with the defect, and the ulnar end of the flap, which was to become the posterior end of the palate, was designed to be concave. During the first operation, half of the f lap was raised, the proximal and distal ends of the palmaris longus tendon were cut, and the distal end was displaced distally to obtain a sufficient length. The 2 pieces of the oral mucosal grafts were grafted onto the palmaris longus tendon (Fig. 2). The flap was again secured to the donor. Three weeks after this prefabrication, the radial forearm flap was raised completely with the palmaris longus tendon. After the radial forearm free f lap transfer, the radial artery and concomitant vein were anastomosed to the facial artery and external jugular vein, and the radial forearm flap was sutured to the defect with an open rhinopharynx. After the bilateral incision of the lateral pharyngeal wall, both ends of the palmaris longus tendon were secured to the bilateral superior constrictor muscles. Finally, the superiorly based pharyngeal flap with www.annalsplasticsurgery.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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& Volume 74, Number 4, April 2015
FIGURE 1. CT demonstrates hard and soft palate defect (above). After resection of the palate, nasal cavity can be seen from the mouth.
FIGURE 2. Image of the prefabrication. Above left, The radial forearm f lap was designed to correspond with the defect, and the ulnar side of the f lap was designed to be concave. Below left, Half of the f lap was raised, and the palmaris longus tendon was displaced distally. Above right, Two pieces of the oral mucosa were grafted onto the palmaris longus tendon. The space between the 2 mucosal grafts is necessary for the pharyngeal f lap, which will be sutured with forearm f lap. 438
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Plastic Surgery
& Volume 74, Number 4, April 2015
Reconstruction of Velopharyngeal Function
FIGURE 3. Above left, The design of the superiorly based pharyngeal flap and incision to identify the superior constrictor muscle (arrows). Above right, The flap has sufficient vessel and palmaris longus tendon length on both sides. Below, The oral mucosal grafts had completely survived on the palmaris longus tendon. Below right, The radial forearm flap was sutured into the mouth. Both ends of the flap (originally the ulnar side of the flap) were sutured to the lateral pharyngeal wall. Furthermore, the palmaris longus tendon was secured to the constrictor muscle (double arrow), and the pharyngeal flap was sutured to the middle of the posterior margin of the forearm flap.
half the width of the posterior pharyngeal wall was raised and secured to the posterior margin of the forearm flap between the 2 oral mucosal grafts (Fig. 3).
RESULTS There were no wound-related or microsurgical complications. Nasoendoscopic examination performed 2 weeks after the operation revealed the existence of bilateral velopharyngeal port and lateral pharyngeal wall movement. We started swallowing therapy 4 weeks after the surgery. Videofluoroscopic examination 14 weeks after the surgery showed that the patient could intake both liquid and thickened diets without any regurgitation or aspiration. Twelve weeks after the operation, the patient could resume oral intake without any difficulties (Fig. 4). Finally, 6 months postoperatively, the gastrostomy tube and tracheotomy could be removed. Currently, the patient has no sleep apnea, and his speech intelligibility has changed from severe to minimal hypernasality (see Video, Supplemental Digital Content 1, http://links.lww.com/SPA/A78, which demonstrates the videofluoroscopic examination and speech).
DISCUSSION Disruption of valvular function of the soft palate leads to disturbed speech and difficulty in swallowing. Reconstruction of the palate should not only cover the defect but also provide velopharyngeal function. Reconstruction after ablation surgery for oropharyngeal cancer involving the soft palate is always challenging for head and neck reconstructive surgeons. To reconstruct the velopharyngeal function after full-palate resection, it is necessary to undertake 3 tasks. The first task is to cover the large palatal defect and separate the nasal cavity from the * 2015 Wolters Kluwer Health, Inc. All rights reserved.
oral cavity to prevent speech difficulty such as hypernasal speech. However, complete occlusion of nasopharyngeal space leads to respiratory disturbance. Therefore, the second task is to maintain the rhinopharyngeal space to prevent sleep apnea, and the third is to close the rhinopharyngeal space during swallowing to prevent nasal regurgitation of food. The conventional solution to cover the palatal defect has been to obturate this area with a palatal prosthesis. However, placement of a palatal prosthesis has several disadvantages, including discomfort, malodor, persistent velopharyngeal insufficiency (particularly in patients with large defects), elimination of sensory feedback from the intact mucosa, and social awkwardness inherent in having a large oral prosthesis.8 To circumvent these problems, several f laps have been used for reconstruction of the palate.1Y5 Recently, the radial forearm free f lap has been commonly used for reconstruction of the palate6Y9 because the skin is thin, pliable, abundant, and well vascularized, which allows for considerable freedom in f lap design. To obtain valvular function of the reconstructed palate, some reconstructive techniques using the radial forearmYpalmaris longus tenocutaneous free f lap have recently been reported. McCombe et al7 reported use of the radial forearmYpalmaris longus tenocutaneous free f lap for reconstruction of defect comprising 50% to 100% of the soft palate. In their technique, tendons were sutured to the oropharyngeal musculature as far, posteriorly and superiorly, as possible to elevate the posterior margin of the palate. However, palate motion was very limited or absent in patients with defects of greater than 75% of the palate. In 2009, Roh et al6 tried to reconstruct moderately sized defects (from small defects to large postoncologic defects involving more than three fourths of the soft palate) by using the forearmYpalmaris longus tenocutaneous free flap. In their report, the www.annalsplasticsurgery.com
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439
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Nuri et al
FIGURE 4. Nasoendoscopic view and videofluoroscopy 14 weeks after the surgery. Above, Postoperative view. Below, Nasoendoscopic view shows the pharyngeal flap (middle) and bilateral velopharyngeal port (arrows). Right, Videofluoroscopic image shows no regurgitation or aspiration.
& Volume 74, Number 4, April 2015
palmaris longus tendons were connected between the remnant muscles of the lateral pharyngeal constrictor muscle and the remaining free margin of the levator veli palatini muscle on the contralateral side. Such concept to reconstruct the valvular function of the soft palate by using the remnant levator muscle is ideal. However, the functional outcome depends on the amount of remnant oropharyngeal and palatal musculature after cancer resection. Roh et al reported that patients who had undergone resection of more than three fourths of the palate failed to exhibit velopharyngeal closure on phonation. The pharyngeal f lap has been considered to be the workhorse f lap in treating congenital velopharyngeal insufficiency. The purpose of the pharyngeal f lap procedure is to enable velopharyngeal closure for speech and swallowing without causing obstruction of the nasal airway. Brown et al9 reconstructed palate defects using a radial forearm flap in conjunction with a superiorly based pharyngeal f lap. In their report, the additional pharyngeal flap showed a speech advantage. However, in the subjective assessment of swallowing, the additional pharyngeal flap group did not show an obvious advantage. Static palatal reconstruction using a forearm flap with a pharyngeal f lap can limit the airway but cannot prevent regurgitation of the diet. The width of the pharyngeal flap should be determined by considering the lateral pharyngeal wall motion. Sullivan et al10 suggested that preoperative videofluoroscopic studies are important to determine the extent of lateral pharyngeal movement. Shapiro et al11 created a resting velopharyngeal port that measured at least 20 mm2 to assist in normal speech production after reconstruction of soft palate defects with a superiorly based pharyngeal flap. Hogan and Schwartz12 recommended that the lateral port should be no larger than 20 mm2 to prevent velopharyngeal insufficiency during reconstruction of the soft palate in the treatment of cleft palate and other congenital defects. However, there are no standards for adult patients who have undergone palate resection. We decided that the width of the pharyngeal f lap would be 50% of the width of the pharynx because the lateral pharyngeal wall motion was normal. The velopharyngeal ports were larger than 20 mm2 as a result. To avoid nasal regurgitation during swallowing, reconstruction of dynamic velopharyngeal function is needed. In the normal velopharyngeal closure movement, contraction of the pharyngeal wall, elevation and elongation of the soft palate, and anterior excursion of the posterior pharyngeal wall can be observed. In our case, the levator veli muscle was fully resected with the tumor; therefore, we attempted to secure the palmaris longus tendon to the superior constrictor muscle. We speculated that the superior constrictor muscle and palmaris longus tendon would create a horizontal muscle sling. Contraction of the superior constrictor muscle tows the palmaris longus tendon, which leads to closure of the velopharyngeal port (Fig. 5). Furthermore, the palmaris longus tendon
FIGURE 5. Schematic illustration of reconstructed velopharyngeal function. Superior constrictor muscle and palmaris longus tendon form the horizontal muscle sling, and contraction of the superior constrictor muscle affects shrinkage of the sling. 440
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* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
& Volume 74, Number 4, April 2015
Reconstruction of Velopharyngeal Function
might play a role in preventing contraction of the forearm flap. The palmaris longus tendon has proven to be useful in various postoncologic reconstructions in the head and neck area13,14; however, the tendon is not vascularized, and surgeons must therefore take care to prevent infection. To avoid exposure of the palmaris longus tendon to the nasal cavity, we grafted the oral mucosa onto the palmaris longus tendon during the first operation. The nonepithelialized side of the radial forearm causes contraction of the flap, resulting in the flap being drawn away from the posterior pharyngeal wall. Brown et al9 suggested that a superiorly pharyngeal flap sutured to the nonepithelialized side of the radial forearm flap would reduce contraction of the radial forearm flap. In our technique, the operation is performed in 2 steps: mucosal grafting reduces the nonepithelialized area of the radial forearm flap, which reduces the contraction of the forearm flap. Furthermore, during the first operation, the position of the palmaris longus tendon can be shifted distally to gain sufficient length for formation of the sling. Microsurgical reconstructive techniques have revolutionized postablative reconstruction of the head and neck. However, there is a limit to reconstruction of the dynamic function of the palate solely by the free flap technique. Our technique is a combination of the latest technique using the radial forearmYpalmaris longus tenocutaneous free f lap and the traditional method of treating velopharyngeal insufficiency. As the videofluoroscopic and speech study results show, the present patient obtained normal swallowing function, and speech intelligibility changed from severe to minimal hypernasality. These results show that our technique can be one of the best reconstructive choices for full-palate defects, although further studies are important to substantiate these results.
2. Thomson CJ, Allison RS. The temporalis muscle flap in intraoral reconstruction. Aust N Z J Surg. 1977;67:878Y882. 3. Hanasono MM, Utley DS, Goode RL. The temporalis muscle flap for reconstruction after head and neck oncologic surgery. Laryngoscope. 2001;111: 1719Y1725. 4. Genden EM, Lee BB, Urken ML. The palatal island flap for reconstruction of palatal and retromolar trigone defect revisited. Arch Otolaryngol Head Neck Surg. 2001;127:837Y841. 5. Moore BA, Magdy E, Netterville JL, et al. Palatal reconstruction with the palatal island flap. Laryngoscope. 2003;113:946Y951. 6. Roh TS, Lee WJ, Choi EC, et al. Radial forearmYpalmaris longus tenocutaneous free flap; implication in the repair of the moderate-sized postoncologic soft palate defect. Head Neck. 2009;31:1220Y1227. 7. McCombe D, Lyons B, Winkler R, et al. Speech and swallowing following radial forearm flap reconstruction of major soft palate defects. Br J Plast Surg. 2005;58:306Y311. 8. Lacombe V, Blackwell KE. Radial forearm free flap for soft palate reconstruction. Arch Facial Plast Surg. 1999;1:130Y132. 9. Brown JS, Zuydam AC, Jones DC, et al. Functional outcome in soft palate reconstruction using radial forearm free flap in conjunction with a superiorly based pharyngeal flap. Head Neck. 1997;19:524Y534. 10. Sullivan SR, Marrinan EM, Mulliken JB. Pharyngeal flap outcome in nonsyndromic children with repaired cleft palate and velopharyngeal insufficiency. Plast Reconstr Surg. 2010;125:290Y298. 11. Shapiro BM, Komisar A, Silver C, et al. Primary reconstruction of palate defect. Otolaryngol Head Neck Surg. 1986;95:581Y585. 12. Hogan VM, Schwartz MF. Velopharyngeal incompetence. In: Converse JM, ed. Reconstructive Plastic Surgery: Principles and Procedure in Correction, Reconstruction, and Transplantation. 2nd ed. Vol. 4. Philadelphia, Pa: W.B. Saunders; 1977:2268Y2295. 13. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower lip and chin with the composite radial forearmYpalmaris longus free flap. Plast Reconstr Surg. 1991;88:209Y214. 14. Chantrain G, Deraemaecker R. Glottic reconstruction after cricohyoidoepiglottopexy with a radial forearm free flap that includes the tendon of the palmaris longus: preliminary results and perspectives. Laryngoscope. 1994;104:1035Y1040.
Annals of Plastic Surgery
REFERENCES 1. Zoller J, Maiser H. Intraoral cheek transposition flap for primary reconstruction of the soft palate. Int J Oral Maxillofac Surg. 1992;21:156Y159.
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