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Reconstruction following partial maxillectomy incorporating a muco-periosteal island flap
R E C O N S T R U C T I O N FOLLOWING PARTIAL MAXILLECTOMY INCORPORATING A M U C O - P E R I O S T E A L ISLAND FLAP By D. O. MAISELS,M.B., F.R.C.S.Ed., and Z. L. GIEDROJC-JURAHA,Lekarz of Medicine
Liverpool Regional Burns and Plastic Unit, Whiston Hospital, Prescot, Lancashire THE wise exercise of power demands a sense of responsibility as much in the surgery of malignant disease of the head and neck as it does in other spheres of life. Steady progress has been made in recent years in respect of safe endotracheal ana:sthesia, supplemented on occasion by controlled hypotension, the ready availability of blood transfusions, antibiotics and skilled post-operative care, which includes an improved understanding of the metabolic requirements of the patient and the care of tracheostomies, etc. All of these advances, and many others besides, have increased the scope of surgery for malignant disease of the head and neck to a point where the decision to operate may become a philosophical rather than a technical one, for this increased power to ablate carries with it an increased responsibility to reconstruct the mutilation inflicted by the excision. This dilemma, or seeming conflict between adequate ablation and optimal reconstruction, has led to considerable debate in the past as to what particular type of surgeon should do the ablation. It was said that if a reconstructive surgeon were allowed to excise the turnour, he would skimp on the excision in order to preserve tissue for the reconstruction. In point of fact, however, experience has shown that a properly trained reconstructive surgeon will always excise adequately and often even more radically than his general surgical colleague. Secure in the knowledge that virtually any defect can be]repaired by modern methods, the reconstructive surgeon is much less likely to be appalled and therefore limited by the mutilation he is inflicting. It is not our wish or intention to become involved in a lengthy debate on this subject, but merely to observe that we approve of the increasing tendency throughout the world for this type of surgery to pass into the hands of surgeons who are properly trained both in general and in plastic and reconstructive surgery. It is our belief that the reconstruction of surgically created defects demands standards which are at least as high as those applied to cosmetic surgery. This being the case, any procedure, however minor, which contributes to the rehabilitation Ofthe patient is therefore worth doing and if new, worth reporting. Case Report.--Mrs M. E. McN, was a 55-year-old widow who lived alone and was admitted to a medical ward suffering from a very severe degree of anmmia. After hmmatological investigation and a trial of treatment, this was thought to be a simple iron-deficiency anaemiaof nutritional origin. It responded very well to simple treatment on which the ha:moglobin concentration rose from 5"8 g. per cent. to I2.I g. per cent. in the space of four weeks. We were asked to see the patient on account of an ulcer in her mouth. The patient, who smoked 5 to Io cigarettes a day and rarely took alcohol, admitted to having noticed this ulcer only four weeks prior to admission. On examination, she proved to be edentulous. There was a 2'5 cm. ulcer involving the right upper alveolus and adjacent hard palate (Fig. I). Scattered flecks of leukoplakia were present on the rest of the palatal mucosa. There were no palpably enlarged nodes in the neck, the chest X-ray was clear and appropriate X-rays of the maxilla showed no evidence of bone destruction. The Wassermann test was negative I/2. 48
FIG. I
FIG. 2
Fig. : .--Showing the tumour on the right alveolus and hard palate. Fig. 2 . - - T h e exposure obtained by turning back the cheek.
FIG. 3 The transfer of an island flap of palatal muco-periosteum. A, The solid black area represents unsupported nasal rnucosa, with the remains of the antral cavity lateral to it. B, Dissecting the greater palatine vessels from the under surface of the palatal flap. C, Cutting the island flap from the main palatal flap, while preserving the vessels. D, The island flap separated. E, The island flap rotated to cover the mucosa in the nostril floor.
ID
A
FIG. 4
B
A, The island flap. B, Explanatory line drawing.
A
FIG. 5
B
A~ The island flap in its new position. Bj Explanatory line drawing.
RECONSTRUCTION FOLLOWING PARTIAL MAXlLLECTOMY
51
The clinical diagnosis was confirmed on biopsy of the ulcer, the histological picture being that of a well differentiated squamous cell carcinoma, and the patient accepted our advice to undergo surgical excision. Operation: 1.9.67.--Operation was carried out with the patient under endotracheal anmsthesia, using Halothane and induced hypotension. Through a Fergusson type incision (Fig. 2) the tumour was circumscribed by a wide margin, taking half the hard palate and alveolus to behind the maxillary tuberosity. The fuU thickness of the hard palate was taken, entering the maxillary antrum but leaving the remaining antral mucosa in situ, in its roof. Medially the line of section was along the midline, shelving upwards and laterally in order to leave the medial wall
FIG. 6 T h e closure.
FIG. 7 T h e excised specimen.
of the antrum. Part of the bony floor of the nostril was taken with the specimen exposing the mucosa above. The antral cavity was left open, but the unsupported nasal mucosa was covered by a muco-periosteal island flap from the left side of the palate, carried on the greater palatine vessels (Figs. 3 to 5). An island flap was chosen in preference to simply transposing the whole Veau flap, since it rotated more readily and lay more happily in the defect without distorting or interfering with the remaining soft palate. The facial incision was closed by careful approximation of the skin edges (Fig. 6). The excised specimen (Fig. 7) was reported as follows : " Macroscopic examination: A portion of maxilla, comprising hard palate and alveolar margin. It bears an ulcer 2"5 cm. in diameter. Microscopic examination : Right upper alveolar marginwSquamous cell carcinoma. The tumour is of weU-differentiated pattern, forming frequent epithelial pearls. It does not extend very deeply, but in parts reaches the superficial layers of the bone. Excision appears complete." The patient made an uneventful recovery from her operation, but because of the home circumstances was not discharged until the 2oth post-operative day. She has since been followed up as an out-patient and is making good progress. In view of the leukoplakic changes in her mouth, very close surveillance will be necessary and no doubt in due course further surgery will prove necessary.
52
BRITISH JOURNAL OF PLASTIC SURGERY
DISCUSSION Credit for the first description of a vascular island flap probably belongs to Monks (I898), though the name of Esser (I917) is perhaps more widely associated with this technique. Recent years have seen a number of descriptions of island flaps in various parts of the body. Kernahan and Littlewood (I96I) and Converse and Wood-Smith (I963) were concerned with facial reconstruction, Littler (I96o) with the hand and Moberg (1964) and Snyder and Edgerton (I965) with the foot, while Barron and Emmett (I965) used a simple subcutaneous tissue pedicle as opposed to a vascular pedicle for their island flaps to the face, limbs and trunk. Wilson (I967) has used island flaps for the resurfacing ofintra-oral defects, including the palate, following cancer excisions, while Wallace (I966) modified one of Esser's original operations in order to close fistulm resulting from clefts of the palate. Millard in I962 described an island flap of palatal mucoperiosteum carried on the greater palatine vessels and used to supplement the nasal layer when lengthening the soft palate in congenital clefts. In a further contribution in I966, he showed how this flap could be used to resurface small defects in the lining of the cheek. Having used MiUard's island flaps in a large number of cleft palate repairs, it seemed the obvious choice in the present case for bolstering the unsupported mucosa in the floor of the nose. It may well be that its use was superfluous, but had this area of nasal mucosa broken down, the patient would hzve been faced with the unpleasant consequences of a large oro-nasal fistula. We feel that the use of this flap ifi the present case illustrates two points. In the first place, it is a further indication of the versatility of this particular flap. Secondly, perhaps of greater importance, it is a measure of the degree to which one should strive in immediate reconstructive surgery following cancer ablation. On the one hand, the procedure itself is relatively simple and adds very little to the surgery, while on the other, the potential benefit to the patient is disproportionately great. SUMMARY A case of partial maxillectomy for squamous cell carcinoma arising on the alveolus is described. T h e excision resulted in a bony defect in the nostril floor. This was repaired by a muco-periosteal island flap, carried on the contralateral greater palatine vessels. We are grateful to Dr Norton Williams for his skilled amesthesia and to Dr A. S. Woodcock for the histological reports. Our thanks are also due to Mr M. Bayliss for help with the illustrations. REFERENCES BARRON,J. N. and EMMETT,A. J. J. (1965). Br. ft. plast. Surg. I8, 51. CONVERSE,J. M. and WOOD-SMITH,n . (1963). Plastic reconstr. Surg. 3I, 521. ESSER, J. F. S. (1917). Ann. Surf. 65, 297. KERNAHAN,D. A. and LITTLEWOOD,A. H. M. (1961). Plastic reconstr. Surg. 28, 2o7. LITTLER, J. W. (196o). Trans. int. Soc. plast. Surg., 2nd Congr., London, 1959, p. 175. Edinburgh : Livingstone. MILLARD, n . R. (1962). Plastic reconstr. Surg. 29, 4o. (1966). Plastic reconstr. Surg. 38, 330. MOBERG, E. (1964). Quoted by Snyder, G. B. and Edgerton, M. T. (1965). MONKS, G. H. (1898). Boston reed. surg. ft. I]9 , 385. SNYDER, G. B. and EDGERTON,M. T. (1965). Plastic reconstr. Surg. 36, 518. WALLACE,A. F. (1966). Br. J. plast. Surg. 19, 322. WILSON, J. S. P. (1967). Br. ft. plast. Surg. 2o, 278.
Liverpool Regional Burns and Plastic Unit, Whiston Hospital, Prescot, Lancashire THE wise exercise of power demands a sense of responsibility as much in the surgery of malignant disease of the head and neck as it does in other spheres of life. Steady progress has been made in recent years in respect of safe endotracheal ana:sthesia, supplemented on occasion by controlled hypotension, the ready availability of blood transfusions, antibiotics and skilled post-operative care, which includes an improved understanding of the metabolic requirements of the patient and the care of tracheostomies, etc. All of these advances, and many others besides, have increased the scope of surgery for malignant disease of the head and neck to a point where the decision to operate may become a philosophical rather than a technical one, for this increased power to ablate carries with it an increased responsibility to reconstruct the mutilation inflicted by the excision. This dilemma, or seeming conflict between adequate ablation and optimal reconstruction, has led to considerable debate in the past as to what particular type of surgeon should do the ablation. It was said that if a reconstructive surgeon were allowed to excise the turnour, he would skimp on the excision in order to preserve tissue for the reconstruction. In point of fact, however, experience has shown that a properly trained reconstructive surgeon will always excise adequately and often even more radically than his general surgical colleague. Secure in the knowledge that virtually any defect can be]repaired by modern methods, the reconstructive surgeon is much less likely to be appalled and therefore limited by the mutilation he is inflicting. It is not our wish or intention to become involved in a lengthy debate on this subject, but merely to observe that we approve of the increasing tendency throughout the world for this type of surgery to pass into the hands of surgeons who are properly trained both in general and in plastic and reconstructive surgery. It is our belief that the reconstruction of surgically created defects demands standards which are at least as high as those applied to cosmetic surgery. This being the case, any procedure, however minor, which contributes to the rehabilitation Ofthe patient is therefore worth doing and if new, worth reporting. Case Report.--Mrs M. E. McN, was a 55-year-old widow who lived alone and was admitted to a medical ward suffering from a very severe degree of anmmia. After hmmatological investigation and a trial of treatment, this was thought to be a simple iron-deficiency anaemiaof nutritional origin. It responded very well to simple treatment on which the ha:moglobin concentration rose from 5"8 g. per cent. to I2.I g. per cent. in the space of four weeks. We were asked to see the patient on account of an ulcer in her mouth. The patient, who smoked 5 to Io cigarettes a day and rarely took alcohol, admitted to having noticed this ulcer only four weeks prior to admission. On examination, she proved to be edentulous. There was a 2'5 cm. ulcer involving the right upper alveolus and adjacent hard palate (Fig. I). Scattered flecks of leukoplakia were present on the rest of the palatal mucosa. There were no palpably enlarged nodes in the neck, the chest X-ray was clear and appropriate X-rays of the maxilla showed no evidence of bone destruction. The Wassermann test was negative I/2. 48
FIG. I
FIG. 2
Fig. : .--Showing the tumour on the right alveolus and hard palate. Fig. 2 . - - T h e exposure obtained by turning back the cheek.
FIG. 3 The transfer of an island flap of palatal muco-periosteum. A, The solid black area represents unsupported nasal rnucosa, with the remains of the antral cavity lateral to it. B, Dissecting the greater palatine vessels from the under surface of the palatal flap. C, Cutting the island flap from the main palatal flap, while preserving the vessels. D, The island flap separated. E, The island flap rotated to cover the mucosa in the nostril floor.
ID
A
FIG. 4
B
A, The island flap. B, Explanatory line drawing.
A
FIG. 5
B
A~ The island flap in its new position. Bj Explanatory line drawing.
RECONSTRUCTION FOLLOWING PARTIAL MAXlLLECTOMY
51
The clinical diagnosis was confirmed on biopsy of the ulcer, the histological picture being that of a well differentiated squamous cell carcinoma, and the patient accepted our advice to undergo surgical excision. Operation: 1.9.67.--Operation was carried out with the patient under endotracheal anmsthesia, using Halothane and induced hypotension. Through a Fergusson type incision (Fig. 2) the tumour was circumscribed by a wide margin, taking half the hard palate and alveolus to behind the maxillary tuberosity. The fuU thickness of the hard palate was taken, entering the maxillary antrum but leaving the remaining antral mucosa in situ, in its roof. Medially the line of section was along the midline, shelving upwards and laterally in order to leave the medial wall
FIG. 6 T h e closure.
FIG. 7 T h e excised specimen.
of the antrum. Part of the bony floor of the nostril was taken with the specimen exposing the mucosa above. The antral cavity was left open, but the unsupported nasal mucosa was covered by a muco-periosteal island flap from the left side of the palate, carried on the greater palatine vessels (Figs. 3 to 5). An island flap was chosen in preference to simply transposing the whole Veau flap, since it rotated more readily and lay more happily in the defect without distorting or interfering with the remaining soft palate. The facial incision was closed by careful approximation of the skin edges (Fig. 6). The excised specimen (Fig. 7) was reported as follows : " Macroscopic examination: A portion of maxilla, comprising hard palate and alveolar margin. It bears an ulcer 2"5 cm. in diameter. Microscopic examination : Right upper alveolar marginwSquamous cell carcinoma. The tumour is of weU-differentiated pattern, forming frequent epithelial pearls. It does not extend very deeply, but in parts reaches the superficial layers of the bone. Excision appears complete." The patient made an uneventful recovery from her operation, but because of the home circumstances was not discharged until the 2oth post-operative day. She has since been followed up as an out-patient and is making good progress. In view of the leukoplakic changes in her mouth, very close surveillance will be necessary and no doubt in due course further surgery will prove necessary.
52
BRITISH JOURNAL OF PLASTIC SURGERY
DISCUSSION Credit for the first description of a vascular island flap probably belongs to Monks (I898), though the name of Esser (I917) is perhaps more widely associated with this technique. Recent years have seen a number of descriptions of island flaps in various parts of the body. Kernahan and Littlewood (I96I) and Converse and Wood-Smith (I963) were concerned with facial reconstruction, Littler (I96o) with the hand and Moberg (1964) and Snyder and Edgerton (I965) with the foot, while Barron and Emmett (I965) used a simple subcutaneous tissue pedicle as opposed to a vascular pedicle for their island flaps to the face, limbs and trunk. Wilson (I967) has used island flaps for the resurfacing ofintra-oral defects, including the palate, following cancer excisions, while Wallace (I966) modified one of Esser's original operations in order to close fistulm resulting from clefts of the palate. Millard in I962 described an island flap of palatal mucoperiosteum carried on the greater palatine vessels and used to supplement the nasal layer when lengthening the soft palate in congenital clefts. In a further contribution in I966, he showed how this flap could be used to resurface small defects in the lining of the cheek. Having used MiUard's island flaps in a large number of cleft palate repairs, it seemed the obvious choice in the present case for bolstering the unsupported mucosa in the floor of the nose. It may well be that its use was superfluous, but had this area of nasal mucosa broken down, the patient would hzve been faced with the unpleasant consequences of a large oro-nasal fistula. We feel that the use of this flap ifi the present case illustrates two points. In the first place, it is a further indication of the versatility of this particular flap. Secondly, perhaps of greater importance, it is a measure of the degree to which one should strive in immediate reconstructive surgery following cancer ablation. On the one hand, the procedure itself is relatively simple and adds very little to the surgery, while on the other, the potential benefit to the patient is disproportionately great. SUMMARY A case of partial maxillectomy for squamous cell carcinoma arising on the alveolus is described. T h e excision resulted in a bony defect in the nostril floor. This was repaired by a muco-periosteal island flap, carried on the contralateral greater palatine vessels. We are grateful to Dr Norton Williams for his skilled amesthesia and to Dr A. S. Woodcock for the histological reports. Our thanks are also due to Mr M. Bayliss for help with the illustrations. REFERENCES BARRON,J. N. and EMMETT,A. J. J. (1965). Br. ft. plast. Surg. I8, 51. CONVERSE,J. M. and WOOD-SMITH,n . (1963). Plastic reconstr. Surg. 3I, 521. ESSER, J. F. S. (1917). Ann. Surf. 65, 297. KERNAHAN,D. A. and LITTLEWOOD,A. H. M. (1961). Plastic reconstr. Surg. 28, 2o7. LITTLER, J. W. (196o). Trans. int. Soc. plast. Surg., 2nd Congr., London, 1959, p. 175. Edinburgh : Livingstone. MILLARD, n . R. (1962). Plastic reconstr. Surg. 29, 4o. (1966). Plastic reconstr. Surg. 38, 330. MOBERG, E. (1964). Quoted by Snyder, G. B. and Edgerton, M. T. (1965). MONKS, G. H. (1898). Boston reed. surg. ft. I]9 , 385. SNYDER, G. B. and EDGERTON,M. T. (1965). Plastic reconstr. Surg. 36, 518. WALLACE,A. F. (1966). Br. J. plast. Surg. 19, 322. WILSON, J. S. P. (1967). Br. ft. plast. Surg. 2o, 278.