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Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis
Int. J. Oral Maxillofac. Surg. 2007; 36: 615–619 doi:10.1016/j.ijom.2007.02.015, available online at http://www.sciencedirect.com
Clinical Paper Reconstructive Surgery
Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis
J.-T. Lee1, L.-F. Cheng1, P.-R. Chen2, C.-H. Wang1, H. Hsu1, S.-H. Chien3, F.-C. Wei4 1 Division of Plastic Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; 2 Department of Otorhinolaryngology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; 3Division of Plastic Surgery, Department of Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; 4Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taipei, Taiwan
J.-T. Lee, L.-F. Cheng, P.-R. Chen, C.-H. Wang, H. Hsu, S.-H. Chien, F.-C. Wei: Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis. Int. J. Oral Maxillofac. Surg. 2007; 36: 615–619. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0–5 mm (mean 2.3 mm). The intraoperative mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8–9 cm in length and 2–2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18–38 mm (mean 28.2 mm) after a mean of 21 months’ follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.
Oral submucous fibrosis can result in progressive restriction of mouth opening. Surgical treatment is indicated for severe cases. Surgery consists of releasing the fibrous bands by incising the mucosa down to the muscle layer from the angle of the mouth to the posterior pharyngeal area, and then resurfacing the raw areas with 0901-5027/070615 + 05 $30.00/0
skin grafts, fresh human amnion, buccal fat pad grafts or various local flaps4,9– 11,16 . In 2001, WEI et al. were the first to use free flaps (bilateral small radial forearm flaps) for the reconstruction of buccal mucosa after surgical release of submucous fibrosis with great success14. They also emphasized the importance of coronoidot-
Key words: oral submucous fibrosis; bipaddled radial forearm flap. Accepted for publication 15 February 2007 Available online 11 May 2007
omy and masticatory muscle myotomy and postoperative rehabilitation in the prevention of relapse due to postoperative inactivity and scarring2,7. In this paper, a modified technique, free bipaddled radial forearm flap using only one forearm donor site to reconstruct the bilateral exposed buccal defects, is described.
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
616
J.T. Lee et al.
Table 1. Patient data Intraoperative ID after myotomy and coronoidotomy
Number of perforators in proximal flap
17
33
2
2 3 5 2 5
18 15 20 13 16
38 33 32 35 42
1 2 2 2 1
41/M 55/M 36/M 38/M
1 0 0 2
12 15 18 16
34 40 35 33
1 1 2 2
46
2.3
16
35.5
Case
Age/ sex
Preoperative ID
1
60/M
3
2 3 4 5 6
38/M 67/F 35/M 40/M 50/M
7 8 9 10 Mean
Intraoperative ID after submucous fibrosis release
Complication
ID at follow-up
Follow-up (months)
20
44
33 25 32 28 35
39 29 22 20 19
21 38 18 32
16 9 8 5
28.2
21.1
Arterial thrombosis, flap survived after exploration
Temporomandibular joint subluxation
ID: interincisal distance (mm).
Patients and methods
A total of 10 patients were admitted to the Buddhist Tzu Chi General Hospital for treatment of oral submucous fibrosis from July 2002 through October 2005 (Table 1). All these patients had advanced trismus with an interincisor distance of no more than 5 mm preoperatively. Patient age, sex, aetiology, history of betel quid chewing, preoperative mouth opening, intraoperative maximal mouth opening, size of the flap, perforator number in the proximal flap, complications, donor site morbidity, maximal mouth opening, and development of oral cancer at follow-up were obtained from retrospective chart review and patient follow-up surveys. Follow-up ranged from 5 to 44 months (mean 21 months). Surgical anatomy of bipaddled forearm flap
The blood supply to the radial forearm flap comes from 9 to 17 septocutaneous perforators of the radial artery, measuring between 0.3 and 0.8 mm in external diameter13,15. These emerge in the lateral intermuscular septum between the brachioradialis and the pronator teres proximally and between the brachioradialis and flexor carpi radialis distally, and run in a transverse orientation relative to the radial artery. According to TIMMONS13, there are two main groups of perforators, one in the proximal half and the other in the distal half of the forearm. The proximal group can be considered as two subgroups. The most proximal perforator arises either close to the origin of the radial artery itself or from the radial recurrent artery. Another major perforator is in the second proximal subgroup13. In the distal half of
the forearm, the perforators arise approximately 1.5 cm proximal to the radial styloid process and recur proximally at 0.4– 1.5 cm intervals13,15. The distal perforators are more numerous (mean number, 9) but smaller than the proximal perforators (mean number, 4)5,8,13,15. On the basis of cadaveric dissections and clinical experience, in the second proximal subgroup, usually 1–3 septocutaneous perforators arise from the radial artery 4–10 cm distal to its bifurcation5,12,13. These anatomical characteristics lead to the design of a bipaddled radial forearm flap with one skin paddle based on the second proximal subgroup perforators and the other on the distal perforators. To obtain an orthograde radial forearm flap with an adequate pedicle length (at least 4 cm) for microvascular anastomosis to the nearest facial artery and its venae comitantes, the proximal flap should be based on the second proximal perforators, rather than the most proximal perforators.
Surgical technique
The surgical procedure consists of (1) release of all the intraoral fibrotic tissue from mouth angle to the posterior pharyngeal wall, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction using a bipaddled radial forearm flap (Fig. 1). Steps 1 and 2 are essentially the technique of WEI and coworkers, which has been well described in previous papers2,14. In brief, the operation is performed by two teams simultaneously. Under endotracheal general anaesthesia, the patient is placed in the supine position with non-dominant forearm prepared for simultaneous harvest of the forearm flap. The buccal mucosa is divided transversely from just behind the mouth angle back to the posterior pharyngeal area at a level of 1 cm below the orifice of Stenson’s duct. Palpation of soft, pliable tissue at the resultant defect verifies complete release of fibrous tissue. The coronoid process is exposed through the
Fig. 1. Bipaddled radial forearm flap. Flap length is 8–9 cm and width 2–2.5 cm. Bridge pedicle length is 8–10 cm.
Bipaddled radial forearm flap for reconstruction of bilateral buccal defects
Fig. 2. Labiobuccal vestibular incision.
anterior border of the mandibular ramus. Myotomy of the fibrotic buccinator, temporalis and masseter muscles is performed and followed by a coronoidotomy bilaterally. At this point, the dimensions of the resultant mucosa defects are measured, which are typically 2–2.5 cm wide and 8–9 cm long. A horizontal labiobuccal vestibular incision is made 1 cm above the labial frenulum. The mucosa is incised and raised from the underlying muscles of the lip and cheek, and the dissection is carried down to the mandibular bone. The periosteum is incised horizontally and subperiosteal dissection is performed (Fig. 2). For the bipaddled radial forearm flap, the long axis of both flaps is perpendicular or slightly oblique to the radial artery and the larger portion of both flaps extends toward the ulnar side. Using a Doppler flowmeter, the course and bifurcation of the radial artery are marked. The proximal flap is outlined after further identifying the septocutaneous perforators with the Doppler. The proximal flap will cover the buccal mucosal defect ipsilateral to the donor forearm. The proximal margin of the proximal flap should be located at least 4 cm distal to the bifurcation. The incision is begun on the proximal margin and the ulnar portion of the flap is gradually elevated to include at least one perforator, which is usually sufficient for flap perfusion. The distal flap, which will cover the contralateral buccal defect, is then outlined. The length of the ‘bridge pedicle’ between these two flaps should always be 8 10 cm. It is easy to include at least one distal perforator, because they are more numerous. The cephalic vein is incorporated within the flap, whenever feasible, and dissected proximally beyond the transverse elbow crease to increase its length. After division of the radial artery and its venae comitantes at the bifurcation,
both skin islands of the bipaddled forearm flap are carefully inset to the mucosal defects. Extraction of the third molars avoids inclination of the flaps between the teeth. The ‘bridge pedicle’ is placed at the anterior vestibule submucously. The recipient facial vessel, ipsilateral to the forearm donor site, is exposed through a 2-cm submandibular incision. The flap pedicle is then passed subcutaneously from the mouth angle down to the recipient vessels. If the cephalic vein is available, it is anastomosed to the external jugular vein. Microvascular anastomoses are then performed in the usual manner. The two donor defects on the forearm are closed primarily after undermining. Postoperatively, the patients are fed a liquid diet through a nasogastric tube for 10 days. Mouth-opening exercises start on the fifth day postoperatively, and intensive exercise is continued for at least 6 months. All patients are asked to stop chewing betel quid. Results
All patients (aged 35–67 years; mean 46 years) had been in the habit of chewing betel quid for 8–30 years. Nine patients were males and one was female. The preoperative mouth opening was 0– 5 mm (mean 2.3 mm). The intraoperative forced mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release by myotomy and coronoidotomy. At least one perforator was included in the proximal flap without difficulty in every case. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. Size of the flaps was 8–9 cm in length and 2–2.5 cm in width. Microvascular anastomosis of the flap pedicle to the facial vasculature was done in eight
617
patients and to the superior thyroid vasculature in the other two patients. The cephalic vein was included within the flap in five patients and it was anastomosed to the external jugular vein. A skin graft was needed to cover the two defects of the donor forearm in the first two patients. The donor defects of the subsequent eight patients were closed primarily. There was no donor site morbidity. Nine flaps survived uneventfully. One flap developed arterial thrombosis 24 h after operation and was salvaged after emergency exploration, removal of thrombus and reanastomosis of the artery. One patient had temporomandibular joint subluxation which required surgical reduction. Two patients needed flap revision due to bulkiness. Three patients (cases 1, 7 and 9) failed to exercise regularly, and experienced a significant relapse. The remaining seven patients did cooperate and exercised daily, and the results were satisfactory. The postoperative mouth opening was 18–35 mm (mean 28.2 mm) after an average follow-up period of 21 months (Fig. 3). The average increase of mouth opening was 25.9 mm, compared with the preoperative interincisor distance. There was an average of 7.3 mm decrease in the size of the mouth opening, compared with the intraoperative interincisor distance. Development of oral cancer was not observed in this series. Discussion
A variety of surgical modalities have been used for the treatment of advanced oral submucous fibrosis. Simple excision of the fibrous bands can increase scarring and exacerbate the condition. Results with split-thickness skin grafting, fresh human amnion or buccal fat pad grafts to cover the raw surfaces after resection of fibrous bands have been disappointing10,14. The incidence of shrinkage, contracture and infection of the grafts was high because oral conditions were poor and the symptoms usually recurred10,14. Resurfacing the defects with various local flaps has several disadvantages. Tongue flaps are bulky and require additional division surgery. Bilateral tongue flaps cause disarticulation and dysphagia and increase the risk of aspiration. Involvement of the tongue (in 38% of cases) may preclude the use of tongue flaps. Both the nasolabial flap and palatal island flap have limited size and difficulty in reaching the posterior raw surface. Use of the nasolabial flap also results in facial scars and requires a second operation for division10,14. The advantages of the technique of bilateral small
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Fig. 3. Case 5. (a) Preoperative interincisal distance was 2 mm. (b) Two perforators, located at 5 cm and 7 cm distal to the bifurcation, were included in the proximal flap. (c) Flap elevated. (d) Viable proximal flap over left buccal area one week after surgery. (e) Viable distal flap over right buccal area one week after surgery. (f) Scar on donor forearm. (g) Interincisal distance was 28 mm, 20 months after surgery.
Bipaddled radial forearm flap for reconstruction of bilateral buccal defects free radial forearm flaps include a wellvascularized skin flap, minimal scar contracture and decreased recurrence of trismus14. There are also major disadvantages: two flaps with two microsurgeries are required, the procedure is more time-consuming and technically demanding, and it involves two forearm donor sites with sacrifice of bilateral radial arteries. Another concern is that 3–19% of these patients will develop oral cancer3,18, and the use of this procedure will eliminate the forearm as a free flap donor site and preclude its future use for oral reconstruction after oral cancer removal. Bisecting or splitting the radial forearm flap or other fasciocutaneous flaps (such as peroneal artery, anterolateral thigh or lateral arm flap) into multiple segments, based on the individual perforators, is not new to most plastic surgeons1,6,17. The unique feature of the present technique is the placement of a ‘bridge pedicle’ between the two skin paddles under the mucosa of the anterior vestibule. With the two skin paddles oriented longitudinally to the radial artery, the entire length of the bipaddled flap will be long enough to cover the bilateral buccal defects. Although the length-to-width ratio ranges from 3:1 to 4:1, the viability of both skin paddles is good because they include at least one axially running perforator. To obtain a pedicle length of at least 4 cm for microsurgical anastomosis to the facial vasculature, the proximal skin paddle should be based on the second proximal perforators13. Another means of obviating the use of a second forearm donor site may be a radial forearm flap that is divided into two separate, independent free flaps6 and inset into both buccal mucosal defects; this would require a second microvascular anastomosis. The advantages of the radial forearm flap include constant vascular anatomy, thin and pliable flap, ease in flap elevation and long vascular pedicle with adequate size for anastomosis. Possible functional and aesthetic morbidities on the donor site are well recognized. A skin graft on the donor site can lead to delayed wound healing and tendon exposure and result in remarkably unsightly scarring. In the first two cases, two split-thickness skin grafts were used to cover the donor defects of the forearm. The resultant unsightly scar was a major drawback. In the subsequent eight cases, the two donor defects were closed primarily after adequate undermining, thus resulting in a more acceptable linear scar (Fig. 3f). The anterolateral thigh flap, in comparison, can
also be raised in the fashion of double skin paddles and used for the same purpose in a thin patient with the advantages of preservation of a major artery, easy elevation and a more acceptable scar. This flap is still more bulky and a thinning procedure is required in many cases. Although the need of routine masticatory muscle myotomy and coronoidotomy is controversial16, the present results agree with previous reports showing that they are important in treating advanced oral submucous fibrosis2,10. During the follow-up period, a 7.3-mm decrease in mouth opening size was noted, and can be attributed to the poor compliance of some patients and more severe form of the disease in this series. This technique of a bipaddled radial forearm flap has the following advantages. (1) It can cover two separate buccal defects, using a single donor site, and obviates the need for a second free flap, thus decreasing donor site morbidity. (2) Only one radial artery is sacrificed to elevate two flaps. (3) Two teams can operate simultaneously to reduce operating time. (4) It avoids a second microvascular anastomosis. (5) A free flap donor site is spared for future use in treating the oral cancer that may follow.
8.
9.
10.
11.
12.
13. 14.
References 1. Bhathena HM, Kavarana NM. Bipaddled, retrograde radial extended forearm flap with microarterial anastomosis for reconstruction in oral cancer. Br J Plast Surg 1988: 41: 354–357. 2. Chang YM, Tsai CY, Kildal M, Wei FC. Importance of coronoidotomy and masticatory muscle myotomy in surgical release of trismus caused by submucous fibrosis. Plast Reconstr Surg 2004: 113: 1949–1954. 3. Cox SC, Walker DM. Oral submucous fibrosis. A review. Aust Dent J 1996: 41: 294–299. 4. Cunha-Gomes D, Kavarana NM, Choudhari C, Rajendraprasad JS, Bhathena HM, Desai PB, Vyas JJ, Gangwal S. Total oral reconstruction for cancers associated with advanced oral submucous fibrosis. Ann Plast Surg 2003: 51: 283–289. 5. El-Khatib HA. Island fasciocutaneous flap based on the proximal perforators of the radial artery for resurfacing of burned cubital fossa. Plast Reconstr Surg 1997: 100: 919–925. 6. Hallock GG. Simultaneous bilateral foot reconstruction using a single radial foream flap. Plast Reconstr Surg 1987: 80: 836–838. 7. Heller F, Wei FC, Chang YM, Tsai CY, Liao HT, Lin CL, Kuo YC. A non-
15.
16.
17. 18.
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tooth-borne mouth-opening device for postoperative rehabilitation after surgical release of trismus. Plast Reconstr Surg 2005: 116: 1856–1859. Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implications. Plast Reconstr Surg 1996: 98: 195–210. Kavarana NM, Bhathena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987: 40: 407– 409. Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995: 24: 433– 439. Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC. Clinical evaluation of different treatment methods for oral submucous fibrosis. A 10-year experience with 150 cases. J Oral Pathol Med 1995: 24: 402– 406. Lin JY, Cheng MH, Wei FC, Song D, Huang WC. Proximal forearm flap based on a septocutaneous vessel from the radial artery. Plast Reconstr Surg 2006: 117: 955–960. Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 1986: 77: 80–92. Wei FC, Chang YM, Kildal M, Tsang WS, Chen HC. Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new, reliable approach. Plast Reconstr Surg 2001: 107: 1679–1683. Weinzweig N, Chen L, Chen ZW. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical study. Plast Reconstr Surg 1994: 94: 675–684. Yeh CY. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996: 25: 130–133. Yousif NJ. Analysis of the distribution of cutaneous perforators in cutaneous flaps. Plast Reconstr Surg 1998: 101: 72–84. Yusuf H, Yong SL. Oral submucous fibrosis in a 12-year-old Bangladeshi boy: a case report and review of literature. Int J Paediatr Dent 2002: 12: 271–276.
Address: Jiunn-Tat Lee Division of Plastic Surgery Departement of Surgery Buddhist Tzu Chi General Hospital Tzu Chi University 707 Section 3 Chung-Yang Road Hualien 970 Taiwan Tel: +886-38222641. E-mail: [email protected]
Clinical Paper Reconstructive Surgery
Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis
J.-T. Lee1, L.-F. Cheng1, P.-R. Chen2, C.-H. Wang1, H. Hsu1, S.-H. Chien3, F.-C. Wei4 1 Division of Plastic Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; 2 Department of Otorhinolaryngology, Buddhist Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; 3Division of Plastic Surgery, Department of Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan; 4Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University, Taipei, Taiwan
J.-T. Lee, L.-F. Cheng, P.-R. Chen, C.-H. Wang, H. Hsu, S.-H. Chien, F.-C. Wei: Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis. Int. J. Oral Maxillofac. Surg. 2007; 36: 615–619. # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0–5 mm (mean 2.3 mm). The intraoperative mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8–9 cm in length and 2–2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18–38 mm (mean 28.2 mm) after a mean of 21 months’ follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.
Oral submucous fibrosis can result in progressive restriction of mouth opening. Surgical treatment is indicated for severe cases. Surgery consists of releasing the fibrous bands by incising the mucosa down to the muscle layer from the angle of the mouth to the posterior pharyngeal area, and then resurfacing the raw areas with 0901-5027/070615 + 05 $30.00/0
skin grafts, fresh human amnion, buccal fat pad grafts or various local flaps4,9– 11,16 . In 2001, WEI et al. were the first to use free flaps (bilateral small radial forearm flaps) for the reconstruction of buccal mucosa after surgical release of submucous fibrosis with great success14. They also emphasized the importance of coronoidot-
Key words: oral submucous fibrosis; bipaddled radial forearm flap. Accepted for publication 15 February 2007 Available online 11 May 2007
omy and masticatory muscle myotomy and postoperative rehabilitation in the prevention of relapse due to postoperative inactivity and scarring2,7. In this paper, a modified technique, free bipaddled radial forearm flap using only one forearm donor site to reconstruct the bilateral exposed buccal defects, is described.
# 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
616
J.T. Lee et al.
Table 1. Patient data Intraoperative ID after myotomy and coronoidotomy
Number of perforators in proximal flap
17
33
2
2 3 5 2 5
18 15 20 13 16
38 33 32 35 42
1 2 2 2 1
41/M 55/M 36/M 38/M
1 0 0 2
12 15 18 16
34 40 35 33
1 1 2 2
46
2.3
16
35.5
Case
Age/ sex
Preoperative ID
1
60/M
3
2 3 4 5 6
38/M 67/F 35/M 40/M 50/M
7 8 9 10 Mean
Intraoperative ID after submucous fibrosis release
Complication
ID at follow-up
Follow-up (months)
20
44
33 25 32 28 35
39 29 22 20 19
21 38 18 32
16 9 8 5
28.2
21.1
Arterial thrombosis, flap survived after exploration
Temporomandibular joint subluxation
ID: interincisal distance (mm).
Patients and methods
A total of 10 patients were admitted to the Buddhist Tzu Chi General Hospital for treatment of oral submucous fibrosis from July 2002 through October 2005 (Table 1). All these patients had advanced trismus with an interincisor distance of no more than 5 mm preoperatively. Patient age, sex, aetiology, history of betel quid chewing, preoperative mouth opening, intraoperative maximal mouth opening, size of the flap, perforator number in the proximal flap, complications, donor site morbidity, maximal mouth opening, and development of oral cancer at follow-up were obtained from retrospective chart review and patient follow-up surveys. Follow-up ranged from 5 to 44 months (mean 21 months). Surgical anatomy of bipaddled forearm flap
The blood supply to the radial forearm flap comes from 9 to 17 septocutaneous perforators of the radial artery, measuring between 0.3 and 0.8 mm in external diameter13,15. These emerge in the lateral intermuscular septum between the brachioradialis and the pronator teres proximally and between the brachioradialis and flexor carpi radialis distally, and run in a transverse orientation relative to the radial artery. According to TIMMONS13, there are two main groups of perforators, one in the proximal half and the other in the distal half of the forearm. The proximal group can be considered as two subgroups. The most proximal perforator arises either close to the origin of the radial artery itself or from the radial recurrent artery. Another major perforator is in the second proximal subgroup13. In the distal half of
the forearm, the perforators arise approximately 1.5 cm proximal to the radial styloid process and recur proximally at 0.4– 1.5 cm intervals13,15. The distal perforators are more numerous (mean number, 9) but smaller than the proximal perforators (mean number, 4)5,8,13,15. On the basis of cadaveric dissections and clinical experience, in the second proximal subgroup, usually 1–3 septocutaneous perforators arise from the radial artery 4–10 cm distal to its bifurcation5,12,13. These anatomical characteristics lead to the design of a bipaddled radial forearm flap with one skin paddle based on the second proximal subgroup perforators and the other on the distal perforators. To obtain an orthograde radial forearm flap with an adequate pedicle length (at least 4 cm) for microvascular anastomosis to the nearest facial artery and its venae comitantes, the proximal flap should be based on the second proximal perforators, rather than the most proximal perforators.
Surgical technique
The surgical procedure consists of (1) release of all the intraoral fibrotic tissue from mouth angle to the posterior pharyngeal wall, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction using a bipaddled radial forearm flap (Fig. 1). Steps 1 and 2 are essentially the technique of WEI and coworkers, which has been well described in previous papers2,14. In brief, the operation is performed by two teams simultaneously. Under endotracheal general anaesthesia, the patient is placed in the supine position with non-dominant forearm prepared for simultaneous harvest of the forearm flap. The buccal mucosa is divided transversely from just behind the mouth angle back to the posterior pharyngeal area at a level of 1 cm below the orifice of Stenson’s duct. Palpation of soft, pliable tissue at the resultant defect verifies complete release of fibrous tissue. The coronoid process is exposed through the
Fig. 1. Bipaddled radial forearm flap. Flap length is 8–9 cm and width 2–2.5 cm. Bridge pedicle length is 8–10 cm.
Bipaddled radial forearm flap for reconstruction of bilateral buccal defects
Fig. 2. Labiobuccal vestibular incision.
anterior border of the mandibular ramus. Myotomy of the fibrotic buccinator, temporalis and masseter muscles is performed and followed by a coronoidotomy bilaterally. At this point, the dimensions of the resultant mucosa defects are measured, which are typically 2–2.5 cm wide and 8–9 cm long. A horizontal labiobuccal vestibular incision is made 1 cm above the labial frenulum. The mucosa is incised and raised from the underlying muscles of the lip and cheek, and the dissection is carried down to the mandibular bone. The periosteum is incised horizontally and subperiosteal dissection is performed (Fig. 2). For the bipaddled radial forearm flap, the long axis of both flaps is perpendicular or slightly oblique to the radial artery and the larger portion of both flaps extends toward the ulnar side. Using a Doppler flowmeter, the course and bifurcation of the radial artery are marked. The proximal flap is outlined after further identifying the septocutaneous perforators with the Doppler. The proximal flap will cover the buccal mucosal defect ipsilateral to the donor forearm. The proximal margin of the proximal flap should be located at least 4 cm distal to the bifurcation. The incision is begun on the proximal margin and the ulnar portion of the flap is gradually elevated to include at least one perforator, which is usually sufficient for flap perfusion. The distal flap, which will cover the contralateral buccal defect, is then outlined. The length of the ‘bridge pedicle’ between these two flaps should always be 8 10 cm. It is easy to include at least one distal perforator, because they are more numerous. The cephalic vein is incorporated within the flap, whenever feasible, and dissected proximally beyond the transverse elbow crease to increase its length. After division of the radial artery and its venae comitantes at the bifurcation,
both skin islands of the bipaddled forearm flap are carefully inset to the mucosal defects. Extraction of the third molars avoids inclination of the flaps between the teeth. The ‘bridge pedicle’ is placed at the anterior vestibule submucously. The recipient facial vessel, ipsilateral to the forearm donor site, is exposed through a 2-cm submandibular incision. The flap pedicle is then passed subcutaneously from the mouth angle down to the recipient vessels. If the cephalic vein is available, it is anastomosed to the external jugular vein. Microvascular anastomoses are then performed in the usual manner. The two donor defects on the forearm are closed primarily after undermining. Postoperatively, the patients are fed a liquid diet through a nasogastric tube for 10 days. Mouth-opening exercises start on the fifth day postoperatively, and intensive exercise is continued for at least 6 months. All patients are asked to stop chewing betel quid. Results
All patients (aged 35–67 years; mean 46 years) had been in the habit of chewing betel quid for 8–30 years. Nine patients were males and one was female. The preoperative mouth opening was 0– 5 mm (mean 2.3 mm). The intraoperative forced mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release by myotomy and coronoidotomy. At least one perforator was included in the proximal flap without difficulty in every case. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. Size of the flaps was 8–9 cm in length and 2–2.5 cm in width. Microvascular anastomosis of the flap pedicle to the facial vasculature was done in eight
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patients and to the superior thyroid vasculature in the other two patients. The cephalic vein was included within the flap in five patients and it was anastomosed to the external jugular vein. A skin graft was needed to cover the two defects of the donor forearm in the first two patients. The donor defects of the subsequent eight patients were closed primarily. There was no donor site morbidity. Nine flaps survived uneventfully. One flap developed arterial thrombosis 24 h after operation and was salvaged after emergency exploration, removal of thrombus and reanastomosis of the artery. One patient had temporomandibular joint subluxation which required surgical reduction. Two patients needed flap revision due to bulkiness. Three patients (cases 1, 7 and 9) failed to exercise regularly, and experienced a significant relapse. The remaining seven patients did cooperate and exercised daily, and the results were satisfactory. The postoperative mouth opening was 18–35 mm (mean 28.2 mm) after an average follow-up period of 21 months (Fig. 3). The average increase of mouth opening was 25.9 mm, compared with the preoperative interincisor distance. There was an average of 7.3 mm decrease in the size of the mouth opening, compared with the intraoperative interincisor distance. Development of oral cancer was not observed in this series. Discussion
A variety of surgical modalities have been used for the treatment of advanced oral submucous fibrosis. Simple excision of the fibrous bands can increase scarring and exacerbate the condition. Results with split-thickness skin grafting, fresh human amnion or buccal fat pad grafts to cover the raw surfaces after resection of fibrous bands have been disappointing10,14. The incidence of shrinkage, contracture and infection of the grafts was high because oral conditions were poor and the symptoms usually recurred10,14. Resurfacing the defects with various local flaps has several disadvantages. Tongue flaps are bulky and require additional division surgery. Bilateral tongue flaps cause disarticulation and dysphagia and increase the risk of aspiration. Involvement of the tongue (in 38% of cases) may preclude the use of tongue flaps. Both the nasolabial flap and palatal island flap have limited size and difficulty in reaching the posterior raw surface. Use of the nasolabial flap also results in facial scars and requires a second operation for division10,14. The advantages of the technique of bilateral small
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Fig. 3. Case 5. (a) Preoperative interincisal distance was 2 mm. (b) Two perforators, located at 5 cm and 7 cm distal to the bifurcation, were included in the proximal flap. (c) Flap elevated. (d) Viable proximal flap over left buccal area one week after surgery. (e) Viable distal flap over right buccal area one week after surgery. (f) Scar on donor forearm. (g) Interincisal distance was 28 mm, 20 months after surgery.
Bipaddled radial forearm flap for reconstruction of bilateral buccal defects free radial forearm flaps include a wellvascularized skin flap, minimal scar contracture and decreased recurrence of trismus14. There are also major disadvantages: two flaps with two microsurgeries are required, the procedure is more time-consuming and technically demanding, and it involves two forearm donor sites with sacrifice of bilateral radial arteries. Another concern is that 3–19% of these patients will develop oral cancer3,18, and the use of this procedure will eliminate the forearm as a free flap donor site and preclude its future use for oral reconstruction after oral cancer removal. Bisecting or splitting the radial forearm flap or other fasciocutaneous flaps (such as peroneal artery, anterolateral thigh or lateral arm flap) into multiple segments, based on the individual perforators, is not new to most plastic surgeons1,6,17. The unique feature of the present technique is the placement of a ‘bridge pedicle’ between the two skin paddles under the mucosa of the anterior vestibule. With the two skin paddles oriented longitudinally to the radial artery, the entire length of the bipaddled flap will be long enough to cover the bilateral buccal defects. Although the length-to-width ratio ranges from 3:1 to 4:1, the viability of both skin paddles is good because they include at least one axially running perforator. To obtain a pedicle length of at least 4 cm for microsurgical anastomosis to the facial vasculature, the proximal skin paddle should be based on the second proximal perforators13. Another means of obviating the use of a second forearm donor site may be a radial forearm flap that is divided into two separate, independent free flaps6 and inset into both buccal mucosal defects; this would require a second microvascular anastomosis. The advantages of the radial forearm flap include constant vascular anatomy, thin and pliable flap, ease in flap elevation and long vascular pedicle with adequate size for anastomosis. Possible functional and aesthetic morbidities on the donor site are well recognized. A skin graft on the donor site can lead to delayed wound healing and tendon exposure and result in remarkably unsightly scarring. In the first two cases, two split-thickness skin grafts were used to cover the donor defects of the forearm. The resultant unsightly scar was a major drawback. In the subsequent eight cases, the two donor defects were closed primarily after adequate undermining, thus resulting in a more acceptable linear scar (Fig. 3f). The anterolateral thigh flap, in comparison, can
also be raised in the fashion of double skin paddles and used for the same purpose in a thin patient with the advantages of preservation of a major artery, easy elevation and a more acceptable scar. This flap is still more bulky and a thinning procedure is required in many cases. Although the need of routine masticatory muscle myotomy and coronoidotomy is controversial16, the present results agree with previous reports showing that they are important in treating advanced oral submucous fibrosis2,10. During the follow-up period, a 7.3-mm decrease in mouth opening size was noted, and can be attributed to the poor compliance of some patients and more severe form of the disease in this series. This technique of a bipaddled radial forearm flap has the following advantages. (1) It can cover two separate buccal defects, using a single donor site, and obviates the need for a second free flap, thus decreasing donor site morbidity. (2) Only one radial artery is sacrificed to elevate two flaps. (3) Two teams can operate simultaneously to reduce operating time. (4) It avoids a second microvascular anastomosis. (5) A free flap donor site is spared for future use in treating the oral cancer that may follow.
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References 1. Bhathena HM, Kavarana NM. Bipaddled, retrograde radial extended forearm flap with microarterial anastomosis for reconstruction in oral cancer. Br J Plast Surg 1988: 41: 354–357. 2. Chang YM, Tsai CY, Kildal M, Wei FC. Importance of coronoidotomy and masticatory muscle myotomy in surgical release of trismus caused by submucous fibrosis. Plast Reconstr Surg 2004: 113: 1949–1954. 3. Cox SC, Walker DM. Oral submucous fibrosis. A review. Aust Dent J 1996: 41: 294–299. 4. Cunha-Gomes D, Kavarana NM, Choudhari C, Rajendraprasad JS, Bhathena HM, Desai PB, Vyas JJ, Gangwal S. Total oral reconstruction for cancers associated with advanced oral submucous fibrosis. Ann Plast Surg 2003: 51: 283–289. 5. El-Khatib HA. Island fasciocutaneous flap based on the proximal perforators of the radial artery for resurfacing of burned cubital fossa. Plast Reconstr Surg 1997: 100: 919–925. 6. Hallock GG. Simultaneous bilateral foot reconstruction using a single radial foream flap. Plast Reconstr Surg 1987: 80: 836–838. 7. Heller F, Wei FC, Chang YM, Tsai CY, Liao HT, Lin CL, Kuo YC. A non-
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tooth-borne mouth-opening device for postoperative rehabilitation after surgical release of trismus. Plast Reconstr Surg 2005: 116: 1856–1859. Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and clinical implications. Plast Reconstr Surg 1996: 98: 195–210. Kavarana NM, Bhathena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987: 40: 407– 409. Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995: 24: 433– 439. Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC. Clinical evaluation of different treatment methods for oral submucous fibrosis. A 10-year experience with 150 cases. J Oral Pathol Med 1995: 24: 402– 406. Lin JY, Cheng MH, Wei FC, Song D, Huang WC. Proximal forearm flap based on a septocutaneous vessel from the radial artery. Plast Reconstr Surg 2006: 117: 955–960. Timmons MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg 1986: 77: 80–92. Wei FC, Chang YM, Kildal M, Tsang WS, Chen HC. Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new, reliable approach. Plast Reconstr Surg 2001: 107: 1679–1683. Weinzweig N, Chen L, Chen ZW. The distally based radial forearm fasciosubcutaneous flap with preservation of the radial artery: an anatomic and clinical study. Plast Reconstr Surg 1994: 94: 675–684. Yeh CY. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996: 25: 130–133. Yousif NJ. Analysis of the distribution of cutaneous perforators in cutaneous flaps. Plast Reconstr Surg 1998: 101: 72–84. Yusuf H, Yong SL. Oral submucous fibrosis in a 12-year-old Bangladeshi boy: a case report and review of literature. Int J Paediatr Dent 2002: 12: 271–276.
Address: Jiunn-Tat Lee Division of Plastic Surgery Departement of Surgery Buddhist Tzu Chi General Hospital Tzu Chi University 707 Section 3 Chung-Yang Road Hualien 970 Taiwan Tel: +886-38222641. E-mail: [email protected]