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Immediate microvascular reconstruction of combined palatal and midfacial defects
Immediate Microvascular Reconstruction of Combined Palatal and Midfacial Defects Kenneth C. Shestak, MD, Mark A. Schusterman, MD, Neil Ford Jones, MD, FRCS, IV0 P. Janecka, MD, Liligham N. Sekhar, MD, Jonas T. Johnson, MD, FACS,Pittsburgh,Pennsylvania
determined by the degree to which restoration of satisfactory function and acceptable appearance may be achieved. The advent of microsurgical free-tissue reconstruction after surgical ablation of such tumors has allowed more sophisticated one-stage reconstruction of these complex defects. Immediate reconstruction has not only improved the quality of life for many of these patients but also improved the survival [1]. Early attempts at palatal reconstruction were marked by the use of local flap tissue. Von Langenbeck [2] led the German school in the 19th century by using local palatal flaps for small defects. This was followed by the use of the pharyngeal flap and extraoral flaps such as the median forehead flap, temporalis muscle flap, tubed cervical flaps, and tubed flaps "waltzed" from the forearm and the upper arm [3-6]. As the specialty of head and neck surgery developed and the techniques of maxillectomy became established, surgeons were faced with more complex wounds, including defects of the palate, orbit, and maxilla. The most prominent technique for autogenous tissue reconstruction of such wounds was staged transfer of tubed cervical flaps as championed by Edgerton and Zovickian [6]. Two basic concepts emerged from their experience, the first being that reconstruction should always be planned and preferably initiated at the time of original resection. Second, the reconstructive plan should be tailored to fit each dvanced cancers (T4) of the paranasal sinuses have specific defect and each individual situation depending always been a difficult problem for the patient and a upon tumor pathology and patient needs. With the application of microsurgical free-tissue formidable challenge for the treating physician. Optimal treatment usually entails a combination of surgery and transfer in head and neck surgery, reconstruction entered radiotherapy. The surgical treatment of these tumors re- a whole new era. A multiplicity of flaps have been used quires extensive ablation which often results in large com- for both immediate and delayed reconstruction. These posite defects of the cheek, palate, and orbital regions. larger composites of vascularized tissue have allowed Few procedures in head and neck surgery produce more more radical and confident resection of tumors, approprisevere functional impairment, devastating physical defor- ately timed institution of radiotherapy, and quicker pamity, and emotional anguish in the patient. Implicit in the tient rehabilitation. In the mid 1960s, Hoopes and Edgerton [7] outlined concept of successful surgical management of this problem is that resection and reconstruction must be used the following five major objectives for the reconstruction of maxillectomy defects: (1) consistently obtaining a together. Recent advances in diagnostic techniques, anesthetic healed wound; (2) restoring palatal competence and management, and multidisciplinary surgical collabora- function; (3) supporting the orbit or filling the orbital tion have permitted resection of tumors extending to the cavity in cases of exenteration; (4) obliterating the maxilcranial base and middle cranial fossa; however, the extent lectomy defect; and (5) restoring facial contour. To to which ablative technique may be reasonably applied is achieve these goals, the latissimus dorsi flap became our From the Divisionof Plastic and ReconstructiveSurgeryand Depart- technique of choice for immediate reconstruction of these mentof Otolaryngology,Universityof Pittsburgh,Pittsburgh,Pennsyl- complex defects. This free-tissue transfer was previously vania. used in the secondary closure of orbitomaxillary defects Requests for reprints shouldbe addressedto KennethC. Shestak, but was adapted for combined palatal and midfacial reMD, 1117ScaifeHall,UniversityofPittsburgh,Pittsburgh,Pennsylvaconstruction at our institution [8,9]. nia 15261. The delayed reconstruction of palatal and maxillecPresentedat the 34th AnnualMeetingof the Societyof Head and tomy defects has been performed by the microvascular Neck Surgeons,New Orleans,Louisiana,May 22-26, 1988.
We describe a method for immediate one-stage reconstruction of combined palatal and midfacial defects using latissimus dorsi musculocutaneous freetissue transfer. It has consistently provided healed wounds, restoration of palatal function, and preservation of facial contour while obviating the need for a palatal prosthesis. This reconstructive method, which uses only autogenous tissue, may offer a significant advantage in cases where more than a hemimaxillectomy is required, for compound defects resulting from the sacrifice of facial structures along with the maxillectomy, and in situations where the resection involves cranial base structures with a resultant need to separate the cranial contents from the oral and nasal cavities. Finally, it provides an alternative to prosthetic rehabilitation for the elderly patient with decreased or absent vision.
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252
THE AMERICAN JOURNAL OF SURGERY VOLUME 156 OCTOBER1988
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Figure 1. Top and palatal defect after extended exenteratlon, and resection of cheek skin. Top skin paddles for both palatal and facial cheek skin reconstruction. Bottom palatal inset is performed first. The flap is then folded on Itself to allow cheek reconstrucUon. the completed facial and palatal reconstruction and pedlcle orientation to mandible and upper neck vessels.
transfer of other free-tissue composites, including the dorsalis pedis flap and the scapula osteocutaneous flap [10, I 1]. However, to our knowledge, no series of immediate, single-stage palatal and midfacial reconstruction has been reported. MATERIAL AND M E T H O D S Over a 26-month period, we treated nine patients who underwent resection of the maxilla and palate for advanced carcinoma (T4), including orbital exenteration in three patients, resection of cheek and nasal skin for tumor invasion in four patients, and tumor excision extending to the cranial base in two patients. The resulting defects included the palate, maxillary sinus, and various combinations of cheek skin, nose, orbit, and skull base (Figure 1, top left).
The operation was performed using a two-team approach which included tumor resection followed by immediate reconstruction. Upon completion of the resection, the facial and intraoral defect was examined and the exact dimensions of the palatal defect measured. The patient was turned to a semilateral position for the latissimus dorsi flap harvest. The skin paddle or paddles were designed on the back skin to meet the specific reconstructive needs for the palate and facial skin (Figure 1, top right). The proximal end of the inscribed skin paddle was designed at least 5 cm below the tip of the scapula to allow for an ample pedicle length (thoracodorsal artery and vein) that could easily reach the neck vessels. The flap was harvested in standard fashion and the entire muscle was taken. The back wound was closed over two suction drains and the patient turned back to the supine position.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156 OCTOBER 1988
253
SHESTAK ET AL
The palatal inset was performed first using everting horizontal mattress sutures before the flap was revascularized (Figure 1, bottom left). In this way, an exact size match of the palatal defect was consistently obtained. The muscle of the flap was trimmed and hemostasis obtained after the microvascular anastomoses were completed. The bulk of the flap was decreased by resecting excess muscle, and the skin paddles used for facial reconstruction were tailored once reperfusion was established. A tunnel was made external to the mandible to allow passage of the pedicle to the recipient vessels in the neck under direct vision, thereby avoiding twists or kinks in the pedicle. The completed facial and palatal reconstruction and pedicle orientation are shown in Figure 1, bottom right. A single suction drain was then placed into the wound and a nasogastric tube was passed. In cases where there was an external skin paddle, the viability of the flap could be easily monitored with an external doppler device by either physicians or nurses, RESULTS The mean operating time for tumor resection and reconstruction in nine patients was 13 hours, including the two position changes noted, and the average hospital stay was 14 days. All patients achieved primary healing with no operative complications noted. Specifically, there were no instances of infection, flap loss, suture line separation, gravitational settling of the flap in the mouth, or donor site problems. All patients demonstrated satisfactory deglutition and intelligible speech. Seven of these patients were treated with postoperative radiotherapy; none showed adverse effects on the flap reconstruction. COMMENTS Microvascular free-tissue transfer has revolutionized many aspects of reconstructive surgery. Nowhere is this more evident than in head and neck reconstruction, where traditionally difficult problems such as mandibular and pharyngoesophageal reconstruction have been greatly facilitated with the use of microsurgery [11,12]. Reconstruction of large palatal defects has long been a difficult problem for which there has been no easy solution. The discomfort and disability in speech, mastication, and swallowing accompanying a defect of the palate are great handicaps [6]. Selection of a reconstructive method should be highly individualized and based on many factors. The traditional management of the maxillectomy wound has included the use of both a split-thickness skin graft to provide epithelial replacement and a palatal prosthesis to obturate the deficit in the palate. This approach is quite satisfactory when the surgical defect involves less than half of the total palate, remaining dentition is adequate to support a prosthesis, and the patient demonstrates the capability and willingness to perform daily prosthesis care. The method provides a minimum of donor site morbidity and allows easy inspection of the maxillectomy cavity to detect possible tumor recurrence. However, prosthetic appliances can be cumbersome and
254
difficult to clean, especially for the elderly patient with monocular or absent vision. In addition, there are a number of inherent disadvantages with palatal prostheses. As already noted herein, dentition must be adequate for the retention of an appliance, and with the passage of time and loss of teeth, this problem becomes magnified. There is often continued leakage between the nasal and oral cavities due to difficulty obtaining an adequate leak-tight seal without irritation, and this in turn leads to further difficulties with speech and oral hygiene. Many patients complain of discomfort where the prosthesis impinges upon mobile structures and the gag area. Finally, the continual reminder of disfigurement which the patient is subjected to by daily appliance care can result in crippling depression and poor patient rehabilitation, further hampering treatment plans. For these reasons, after experience with the repair of congenital palatal clefts, many investigators strongly prefer reconstruction of palatal defects with autogenous tissue [6,7,11,13]. It is logical to assume that microsurgical free-tissue transfer would offer the best possibility of satisfying the complex volume and tissue surface demands produced by extended maxillectomy. After reviewing our experience with skin graft lining and palatal obturation of these defects, it became possible to identify patients who were likely to manage a prosthesis poorly and would have a difficult and prolonged rehabilitation period with such management. These tended to be patients requiring more than a hemimaxillectomy, patients with inadequate remaining dentition, and visually impaired or debilitated persons who demonstrated unwillingness or inability to perform daily prosthesis care. We therefore began advocating flap reconstruction in this group. In addition, we strongly believe that flaps are indicated in patients with compound defects requiring the replacement of facial skin and subcutaneous tissue along with palatal structures and in patients in whom a resection of cranial base structures is needed. The latissimus dorsi musculocutaneous free-flap fulfills all of the criteria for successful reconstruction outlined herein. The basic anatomic characteristics of the flap have been well described elsewhere [14]. The vascular structure is consistent, and the multiple skin perforating vessels allow the design of a large number of skin paddles which can be used to simultaneously reconstruct the palate and facial, orbital, and nasal areas as needed [15]. The muscle bulk is sufficient to obliterate the maxillary defect' and to restore facial contour. The pedicle length and large diameter allow anastomoses to be performed to the facial vessels in the ipsilateral neck without tension or the need for vein grafts. Finally, the donor site morbidity with this muscle transfer procedure is minimal. The proximal portion of the skin paddle of the flap is designed to exactly match the palatal defect (Figure 2) and can be inset easily and accurately, producing an airtight seal (Figure 3). The incorporation of the skin paddle with the muscle in this manner obviates the potential problems of intraoral skin graft loss or subsequent contracture. More importantly, the strength provided by the
THE AMERICAN JOURNAL OF SURGERY VOLUME 156 OCTOBER1988
RECONSTRUCTION OF PALATAL AND MIDFACIAL DEFECTS
inset of the musculocutaneous skin paddle to the mucosal tissues helps support the weight of the flap, preventing gravitational ptosis of the reconstructed palate. In these patients, the flap has been uniformly successful in allowing separation of the oral and nasal cavities and has permitted satisfactory deglutition and intelligible speech. Perhaps most importantly, the latissimus dorsi musculocutaneous flap provides a reliable method for the immediate reconstruction of complex defects. This has minimized the patient's sense of personal disfigurement, permitted quicker rehabilitation, and allowed rapid institution of postoperative radiotherapy, which is often an important part of the treatment plan for patients with these advanced tumors [1]. This method underscores the concept that resection and reconstruction must complement each other. An alternative flap for reconstruction of the palate and midface defects is the free rectus abdominis flap. Its application in the reconstruction of cranial base defects has been described by Jones et al [16]. This flap's reliable cutaneous territory and appropriate muscle bulk make it suitable for midfacial reconstruction. It can be harvested simultaneously with tumor extirpation, and the elimination of position changes make it an attractive alternative. Although the deep inferior epigastric pedicle is of consistent diameter and possesses ample length for most freetissue reconstructions, the distance from the posterior palate to the recipient vessels in the neck may exceed its ability to reach this location without employing vein grafts. Disadvantages of the latissimus flap primarily include the need for two position changes on the operating room table, and the subcutaneous tissue bulk of the flap, which may require secondary defatting of the external skin paddle for optimal cosmesis. The color match between back skin and facial skin may be less than ideal, but our patients did not voice this as a concern. Finally, with the resection of large portions of the maxillary alveolus, there
may be a need for secondary bone grafting or the use of osteointegrated implants to allow fitting of a dental appliance. REFERENCES 1. Konno A, Togawa K, Iizuka K. Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg 1981;67: 440-8. 2. yon Langenbeck B. Die Uranoplastik Mittelst Ablosiing Das Mucosperiostalen Guamenuberzuges. Arch Fur Klinische Chirurgie Bd II. 1862: 205-87. 3. Rotter J. Plastische Operationen in der Mundhohle und an der Nose. Munch Med Wehnschr 1889; 31: 535-7. 4. Blair VP. Operative treatment of difficult cases of palatal defects after infancy. Surg Gynecol Obstet 1911; 12: 289-94. 5. Padgett EC. Repair of cleft palate after unsuccessful operations. Arch Surg 1930; 20: 453-72. 6. Edgerton MT, Zovickian A. Reconstruction of major defects of the palate. Plast Reconstr Surg 1956; 17: 105-28. 7. Hoopes J, Edgerton MT. Surgical rehabilitation following radical maxillectomy and orbital exenteration. Cancer of the head and neck. Md Med J 1966; 15: 91-7. 8. Baker SR. Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps. Head Neck Surg 1984; 6: 828-35. 9. Jones NF, Swartz WM, Hardesty RA, Ramasastry SS, Heckler FR, Newton ED. Extensive and complex defects of the face and scalp: the role of microsurgical reconstruction. Plast Reconstr Surg (in press). 10. Correa Chem R, Franciosi LFN. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery 1983; 4: 35-9. 11. Swartz WM, Banis JC Jr., Newton ED, Ramasastry SS, Jones NF, Ackland RD. The osteocutaneous flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77: 530-45. I2. Coleman J J, Searles JM, Hester TR, et al. Ten years experience with the free jejunal autograft. Am J Surg 1987; 154: 394-8. 13. Edgerton MT, DeVito RV. Reconstruction of palatal defects resulting from treatment of carcinoma of palate, antrum or gingiva. Plast Reconstr Surg 1961; 28: 306-19. 14. Mathes S J, Nahai F. An atlas of muscles and myocutaneous flaps. St. Louis: CV Mosby, 1982: 236-41. 15. Bartlett SP, May JW Jr., Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981; 67: 631-7. 16. Jones NF, Sekhar N, Laligham MD, Schramm VL. The free rectus abdominis muscle flap of the middle and posterior cranial base. Plast Reconstr Surg 1986; 78: 471-7.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156
OCTOBER 1988
255
determined by the degree to which restoration of satisfactory function and acceptable appearance may be achieved. The advent of microsurgical free-tissue reconstruction after surgical ablation of such tumors has allowed more sophisticated one-stage reconstruction of these complex defects. Immediate reconstruction has not only improved the quality of life for many of these patients but also improved the survival [1]. Early attempts at palatal reconstruction were marked by the use of local flap tissue. Von Langenbeck [2] led the German school in the 19th century by using local palatal flaps for small defects. This was followed by the use of the pharyngeal flap and extraoral flaps such as the median forehead flap, temporalis muscle flap, tubed cervical flaps, and tubed flaps "waltzed" from the forearm and the upper arm [3-6]. As the specialty of head and neck surgery developed and the techniques of maxillectomy became established, surgeons were faced with more complex wounds, including defects of the palate, orbit, and maxilla. The most prominent technique for autogenous tissue reconstruction of such wounds was staged transfer of tubed cervical flaps as championed by Edgerton and Zovickian [6]. Two basic concepts emerged from their experience, the first being that reconstruction should always be planned and preferably initiated at the time of original resection. Second, the reconstructive plan should be tailored to fit each dvanced cancers (T4) of the paranasal sinuses have specific defect and each individual situation depending always been a difficult problem for the patient and a upon tumor pathology and patient needs. With the application of microsurgical free-tissue formidable challenge for the treating physician. Optimal treatment usually entails a combination of surgery and transfer in head and neck surgery, reconstruction entered radiotherapy. The surgical treatment of these tumors re- a whole new era. A multiplicity of flaps have been used quires extensive ablation which often results in large com- for both immediate and delayed reconstruction. These posite defects of the cheek, palate, and orbital regions. larger composites of vascularized tissue have allowed Few procedures in head and neck surgery produce more more radical and confident resection of tumors, approprisevere functional impairment, devastating physical defor- ately timed institution of radiotherapy, and quicker pamity, and emotional anguish in the patient. Implicit in the tient rehabilitation. In the mid 1960s, Hoopes and Edgerton [7] outlined concept of successful surgical management of this problem is that resection and reconstruction must be used the following five major objectives for the reconstruction of maxillectomy defects: (1) consistently obtaining a together. Recent advances in diagnostic techniques, anesthetic healed wound; (2) restoring palatal competence and management, and multidisciplinary surgical collabora- function; (3) supporting the orbit or filling the orbital tion have permitted resection of tumors extending to the cavity in cases of exenteration; (4) obliterating the maxilcranial base and middle cranial fossa; however, the extent lectomy defect; and (5) restoring facial contour. To to which ablative technique may be reasonably applied is achieve these goals, the latissimus dorsi flap became our From the Divisionof Plastic and ReconstructiveSurgeryand Depart- technique of choice for immediate reconstruction of these mentof Otolaryngology,Universityof Pittsburgh,Pittsburgh,Pennsyl- complex defects. This free-tissue transfer was previously vania. used in the secondary closure of orbitomaxillary defects Requests for reprints shouldbe addressedto KennethC. Shestak, but was adapted for combined palatal and midfacial reMD, 1117ScaifeHall,UniversityofPittsburgh,Pittsburgh,Pennsylvaconstruction at our institution [8,9]. nia 15261. The delayed reconstruction of palatal and maxillecPresentedat the 34th AnnualMeetingof the Societyof Head and tomy defects has been performed by the microvascular Neck Surgeons,New Orleans,Louisiana,May 22-26, 1988.
We describe a method for immediate one-stage reconstruction of combined palatal and midfacial defects using latissimus dorsi musculocutaneous freetissue transfer. It has consistently provided healed wounds, restoration of palatal function, and preservation of facial contour while obviating the need for a palatal prosthesis. This reconstructive method, which uses only autogenous tissue, may offer a significant advantage in cases where more than a hemimaxillectomy is required, for compound defects resulting from the sacrifice of facial structures along with the maxillectomy, and in situations where the resection involves cranial base structures with a resultant need to separate the cranial contents from the oral and nasal cavities. Finally, it provides an alternative to prosthetic rehabilitation for the elderly patient with decreased or absent vision.
A
252
THE AMERICAN JOURNAL OF SURGERY VOLUME 156 OCTOBER1988
••
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Ji LOotirSfS:~us::r:~inflop with ij'i
tum
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maxlllectomy,orbital left, Bottomright,appearanceof
Figure 1. Top and palatal defect after extended exenteratlon, and resection of cheek skin. Top skin paddles for both palatal and facial cheek skin reconstruction. Bottom palatal inset is performed first. The flap is then folded on Itself to allow cheek reconstrucUon. the completed facial and palatal reconstruction and pedlcle orientation to mandible and upper neck vessels.
transfer of other free-tissue composites, including the dorsalis pedis flap and the scapula osteocutaneous flap [10, I 1]. However, to our knowledge, no series of immediate, single-stage palatal and midfacial reconstruction has been reported. MATERIAL AND M E T H O D S Over a 26-month period, we treated nine patients who underwent resection of the maxilla and palate for advanced carcinoma (T4), including orbital exenteration in three patients, resection of cheek and nasal skin for tumor invasion in four patients, and tumor excision extending to the cranial base in two patients. The resulting defects included the palate, maxillary sinus, and various combinations of cheek skin, nose, orbit, and skull base (Figure 1, top left).
The operation was performed using a two-team approach which included tumor resection followed by immediate reconstruction. Upon completion of the resection, the facial and intraoral defect was examined and the exact dimensions of the palatal defect measured. The patient was turned to a semilateral position for the latissimus dorsi flap harvest. The skin paddle or paddles were designed on the back skin to meet the specific reconstructive needs for the palate and facial skin (Figure 1, top right). The proximal end of the inscribed skin paddle was designed at least 5 cm below the tip of the scapula to allow for an ample pedicle length (thoracodorsal artery and vein) that could easily reach the neck vessels. The flap was harvested in standard fashion and the entire muscle was taken. The back wound was closed over two suction drains and the patient turned back to the supine position.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156 OCTOBER 1988
253
SHESTAK ET AL
The palatal inset was performed first using everting horizontal mattress sutures before the flap was revascularized (Figure 1, bottom left). In this way, an exact size match of the palatal defect was consistently obtained. The muscle of the flap was trimmed and hemostasis obtained after the microvascular anastomoses were completed. The bulk of the flap was decreased by resecting excess muscle, and the skin paddles used for facial reconstruction were tailored once reperfusion was established. A tunnel was made external to the mandible to allow passage of the pedicle to the recipient vessels in the neck under direct vision, thereby avoiding twists or kinks in the pedicle. The completed facial and palatal reconstruction and pedicle orientation are shown in Figure 1, bottom right. A single suction drain was then placed into the wound and a nasogastric tube was passed. In cases where there was an external skin paddle, the viability of the flap could be easily monitored with an external doppler device by either physicians or nurses, RESULTS The mean operating time for tumor resection and reconstruction in nine patients was 13 hours, including the two position changes noted, and the average hospital stay was 14 days. All patients achieved primary healing with no operative complications noted. Specifically, there were no instances of infection, flap loss, suture line separation, gravitational settling of the flap in the mouth, or donor site problems. All patients demonstrated satisfactory deglutition and intelligible speech. Seven of these patients were treated with postoperative radiotherapy; none showed adverse effects on the flap reconstruction. COMMENTS Microvascular free-tissue transfer has revolutionized many aspects of reconstructive surgery. Nowhere is this more evident than in head and neck reconstruction, where traditionally difficult problems such as mandibular and pharyngoesophageal reconstruction have been greatly facilitated with the use of microsurgery [11,12]. Reconstruction of large palatal defects has long been a difficult problem for which there has been no easy solution. The discomfort and disability in speech, mastication, and swallowing accompanying a defect of the palate are great handicaps [6]. Selection of a reconstructive method should be highly individualized and based on many factors. The traditional management of the maxillectomy wound has included the use of both a split-thickness skin graft to provide epithelial replacement and a palatal prosthesis to obturate the deficit in the palate. This approach is quite satisfactory when the surgical defect involves less than half of the total palate, remaining dentition is adequate to support a prosthesis, and the patient demonstrates the capability and willingness to perform daily prosthesis care. The method provides a minimum of donor site morbidity and allows easy inspection of the maxillectomy cavity to detect possible tumor recurrence. However, prosthetic appliances can be cumbersome and
254
difficult to clean, especially for the elderly patient with monocular or absent vision. In addition, there are a number of inherent disadvantages with palatal prostheses. As already noted herein, dentition must be adequate for the retention of an appliance, and with the passage of time and loss of teeth, this problem becomes magnified. There is often continued leakage between the nasal and oral cavities due to difficulty obtaining an adequate leak-tight seal without irritation, and this in turn leads to further difficulties with speech and oral hygiene. Many patients complain of discomfort where the prosthesis impinges upon mobile structures and the gag area. Finally, the continual reminder of disfigurement which the patient is subjected to by daily appliance care can result in crippling depression and poor patient rehabilitation, further hampering treatment plans. For these reasons, after experience with the repair of congenital palatal clefts, many investigators strongly prefer reconstruction of palatal defects with autogenous tissue [6,7,11,13]. It is logical to assume that microsurgical free-tissue transfer would offer the best possibility of satisfying the complex volume and tissue surface demands produced by extended maxillectomy. After reviewing our experience with skin graft lining and palatal obturation of these defects, it became possible to identify patients who were likely to manage a prosthesis poorly and would have a difficult and prolonged rehabilitation period with such management. These tended to be patients requiring more than a hemimaxillectomy, patients with inadequate remaining dentition, and visually impaired or debilitated persons who demonstrated unwillingness or inability to perform daily prosthesis care. We therefore began advocating flap reconstruction in this group. In addition, we strongly believe that flaps are indicated in patients with compound defects requiring the replacement of facial skin and subcutaneous tissue along with palatal structures and in patients in whom a resection of cranial base structures is needed. The latissimus dorsi musculocutaneous free-flap fulfills all of the criteria for successful reconstruction outlined herein. The basic anatomic characteristics of the flap have been well described elsewhere [14]. The vascular structure is consistent, and the multiple skin perforating vessels allow the design of a large number of skin paddles which can be used to simultaneously reconstruct the palate and facial, orbital, and nasal areas as needed [15]. The muscle bulk is sufficient to obliterate the maxillary defect' and to restore facial contour. The pedicle length and large diameter allow anastomoses to be performed to the facial vessels in the ipsilateral neck without tension or the need for vein grafts. Finally, the donor site morbidity with this muscle transfer procedure is minimal. The proximal portion of the skin paddle of the flap is designed to exactly match the palatal defect (Figure 2) and can be inset easily and accurately, producing an airtight seal (Figure 3). The incorporation of the skin paddle with the muscle in this manner obviates the potential problems of intraoral skin graft loss or subsequent contracture. More importantly, the strength provided by the
THE AMERICAN JOURNAL OF SURGERY VOLUME 156 OCTOBER1988
RECONSTRUCTION OF PALATAL AND MIDFACIAL DEFECTS
inset of the musculocutaneous skin paddle to the mucosal tissues helps support the weight of the flap, preventing gravitational ptosis of the reconstructed palate. In these patients, the flap has been uniformly successful in allowing separation of the oral and nasal cavities and has permitted satisfactory deglutition and intelligible speech. Perhaps most importantly, the latissimus dorsi musculocutaneous flap provides a reliable method for the immediate reconstruction of complex defects. This has minimized the patient's sense of personal disfigurement, permitted quicker rehabilitation, and allowed rapid institution of postoperative radiotherapy, which is often an important part of the treatment plan for patients with these advanced tumors [1]. This method underscores the concept that resection and reconstruction must complement each other. An alternative flap for reconstruction of the palate and midface defects is the free rectus abdominis flap. Its application in the reconstruction of cranial base defects has been described by Jones et al [16]. This flap's reliable cutaneous territory and appropriate muscle bulk make it suitable for midfacial reconstruction. It can be harvested simultaneously with tumor extirpation, and the elimination of position changes make it an attractive alternative. Although the deep inferior epigastric pedicle is of consistent diameter and possesses ample length for most freetissue reconstructions, the distance from the posterior palate to the recipient vessels in the neck may exceed its ability to reach this location without employing vein grafts. Disadvantages of the latissimus flap primarily include the need for two position changes on the operating room table, and the subcutaneous tissue bulk of the flap, which may require secondary defatting of the external skin paddle for optimal cosmesis. The color match between back skin and facial skin may be less than ideal, but our patients did not voice this as a concern. Finally, with the resection of large portions of the maxillary alveolus, there
may be a need for secondary bone grafting or the use of osteointegrated implants to allow fitting of a dental appliance. REFERENCES 1. Konno A, Togawa K, Iizuka K. Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg 1981;67: 440-8. 2. yon Langenbeck B. Die Uranoplastik Mittelst Ablosiing Das Mucosperiostalen Guamenuberzuges. Arch Fur Klinische Chirurgie Bd II. 1862: 205-87. 3. Rotter J. Plastische Operationen in der Mundhohle und an der Nose. Munch Med Wehnschr 1889; 31: 535-7. 4. Blair VP. Operative treatment of difficult cases of palatal defects after infancy. Surg Gynecol Obstet 1911; 12: 289-94. 5. Padgett EC. Repair of cleft palate after unsuccessful operations. Arch Surg 1930; 20: 453-72. 6. Edgerton MT, Zovickian A. Reconstruction of major defects of the palate. Plast Reconstr Surg 1956; 17: 105-28. 7. Hoopes J, Edgerton MT. Surgical rehabilitation following radical maxillectomy and orbital exenteration. Cancer of the head and neck. Md Med J 1966; 15: 91-7. 8. Baker SR. Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps. Head Neck Surg 1984; 6: 828-35. 9. Jones NF, Swartz WM, Hardesty RA, Ramasastry SS, Heckler FR, Newton ED. Extensive and complex defects of the face and scalp: the role of microsurgical reconstruction. Plast Reconstr Surg (in press). 10. Correa Chem R, Franciosi LFN. Dorsalis pedis free flap to close extensive palate fistulae. Microsurgery 1983; 4: 35-9. 11. Swartz WM, Banis JC Jr., Newton ED, Ramasastry SS, Jones NF, Ackland RD. The osteocutaneous flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986; 77: 530-45. I2. Coleman J J, Searles JM, Hester TR, et al. Ten years experience with the free jejunal autograft. Am J Surg 1987; 154: 394-8. 13. Edgerton MT, DeVito RV. Reconstruction of palatal defects resulting from treatment of carcinoma of palate, antrum or gingiva. Plast Reconstr Surg 1961; 28: 306-19. 14. Mathes S J, Nahai F. An atlas of muscles and myocutaneous flaps. St. Louis: CV Mosby, 1982: 236-41. 15. Bartlett SP, May JW Jr., Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981; 67: 631-7. 16. Jones NF, Sekhar N, Laligham MD, Schramm VL. The free rectus abdominis muscle flap of the middle and posterior cranial base. Plast Reconstr Surg 1986; 78: 471-7.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156
OCTOBER 1988
255