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Intraoral Reconstruction of Soft Tissue Defects
Intraoral Reconstruction of Soft Tissue Defects RICHARD C. SCHULTZ, M.D., F.A.C.S.*
An erroneous axiom still persists in many reputable medical centers that defects within the mouth should be left to heal by themselves. This unfortunate philosophy may have had its origin in the observation that intraoral wounds and defects will close rapidly by epithelization. Unfortunately, uncontrolled and imprecise healing results in uncontrolled scarring and imprecise functions within the mouth just as it does anywhere else in the body. If a single principle is to be stated it should be: Repair intraoral wounds and defects by primary intention whenever possible. This paper will be primarily concerned with defects in the lining of the mouth and their reconstruction. Without attempting to be encyclopedic, a review of the causes of intraoral defects seems appropriate to introduce methods of reconstruction. The most common indication for intraoral reconstruction is trauma. Auto accidents account for most of these soft-tissue defects. These are commonly lacerations, avulsion flaps, and fractures of teeth, alveolus or bone, and usually require only debridement and primary repair. They should almost never be allowed to heal spontaneously. On the other hand, intraoral war wounds must be managed under different circumstances and often require delayed treatment and secondary reconstruction. Similar to this latter group are defects from animal bites, thermal burns, electrical burns, and radiation ulcers, all of which are usually managed with a plan for secondary reconstruction. The second most common indication for intraoral reconstruction is the presence of a defect resulting from tumor resection. 6 Such a defect, of course, may involve bone and muscle in addition to mucous membrane.
TRAUMA Intraoral lacerations and avulsion flaps are most often created by external forces causing shearing of the lips and cheeks over the *Clinical Assistant Professor of Surgery (Plastic), University of Illinois College of Medicine, Chicago, Illinois Surgical Clinics of North America- Vol. 48, No. 1, February, 1968
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teeth and supporting structures. The injuries are often completely through the lips or cheeks and can be associated with fractures of the teeth, dentures, alveolus, or supporting bone. These intraoral wounds should be repaired promptly, just as one approaches skin wounds. Often conditions do not permit the immediate reduction and fixation of the underlying fractures, but just as a surgeon attempts to achieve early primary closure of skin wounds, he should do the same within the mouth. In addition to minimizing secondary epithelization (scar), prompt repair covers exposed bone and fractures. 2 The choice of suture material within the mouth is worthy of discussion.3 Just as on the skin, nonabsorbable suture causes less tissue reaction and is probably more dependable relative to duration of holding power. On the other hand, absorbable material such as catgut is easy to work with in the mouth and does not usually require removal. This latter characteristic is especially advantageous in cases of children where suture removal may become a problem and may even interfere with the final result. If one chooses to use a nonabsorbable material, preference might be given to silk or one of the softer synthetic materials. Monofilament nylon is stiff and can prove uncomfortable within the mouth, possibly even cutting through the mucous membrane. In any case, a squedged-on needle reduces the trauma of suturing and simplifies suture handling.
SURGICAL DEFECTS As in trauma, prompt repair of elective surgical defects minimizes scarring and reduces morbidity. There is no good reason to permit a fresh surgical defect within the mouth to heal by secondary intention. Such defects usually result from the resection of intraoral malignant growths and are often created by the removal of adjacent teeth or bone resection. In such cases the availability of soft tissue for closure may actually become enhanced by the removal of bony contour, permitting a relatively simple closure of the surgical defect. Where this is not possible, epithelial closure should be planned, either by free grafts or local flaps. I. 4 • 5 Reconstruction by distant pedicle flaps is possible, but is timeconsuming and involves considerable preoperative planning and surgical preparation. 7 Such procedures should be reserved for major defects in which extensive underlying bone reconstruction is necessary. Figure 1 illustrates the use of a free split-thickness skin graft to close an intraoral defect involving the buccal mucosa, a portion of the posterior alveolus, and floor of the mouth. One should select a donor site which is minimally hair-bearing as such a characteristic may persist to some extent within the mouth. A skin graft may shrink and wrinkle for a time during its early phases of healing, but as it matures and adapts to its new location it usually becomes smooth once again and adopts a glistening mucoid surface. Figure 2 illustrates an alternate and, in many ways, an easier approach to reconstructing this same intraoral defect. This method utilizes
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
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local adjacent tissue as a pedicle flap with primary closure of the donor site by undermining. The flap must be elevated without cutting it too thin but when properly planned and executed this method is exceedingly safe and dependable. Secondary surgical procedures are usually not necessary with this type of flap repair.
A ---- Surgical defect
B Cutting graft after outlining with template of defect
c Graft in place
4-0 silk over sponge rubber stent __ _ /
Figure 1. Reconstruction of mucosal defect with split-thickness skin graft. Graft should be of medium thickness and taken from a minimally hair-bearing area.
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C.
SCHULTZ
c Flap outlined
D
E
Rotation of flap
Undermining mucosa
Figure 2. Reconstruction of mucosal defect with local pedicle flap. Flap should not be cut too thin and should be handled delicately. Intraoral sutures may be of either nonabsorbable or absorbable material.
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
125
The tongue has long been used to provide epithelial coverage within the mouth. It provides a marvelously movable donor site, making its use versatile. However, the surgeon must bear in mind that the tongue is a specialized organ and these functions should not be compromised for the sake of expediency. The tongue should not be used as a unit for side-to-side anastomosis
A
B Elevation of tongue flap
c
Tongue flap rotated and sutured into sal defect
D Division of pedicle two weeks later
Figure 3. Reconstruction of mucosal defect with pedicle flap from ventral surface of tongue. Pedicle flap is rotated 90 degrees into mucosal defect. Pedicle may subsequently be divided with aN o. 11 scalpel blade and revisions are seldom necessary.
126
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C.
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to provide closure for a defect in the mouth unless no other choice exists. Such a procedure may provide for initial healing, but cripples the function of the tongue, which can seldom be satisfactorily released. 3 Various flaps can nevertheless be taken from the tongue (without compromising its function) for ingenious reconstruction of defects about the mouth, including the vermilion of the lips. 8 The coarse, specialized epithelium of the dorsum of the tongue will undergo a metaplasia to adapt to the requirements of its new recipient site. Figure 3 illustrates a third alternative for reconstructing the same intraoral defect, using the tongue as a pedicle flap donor site. Such a procedure can be done under local anesthesia with minimal discomfort to the patient. The donor site is closed directly without difficulty. The tongue is tethered to the cheek by the pedicle of this flap for two to three weeks while healing at the periphery of the flap permits the development of an adequate blood supply. The limitation of function of the tongue during this period is surprisingly minimal. A simple division of the pedicle is then generally all that is necessary, and revisions are seldom indicated.
CONTAMINATED WOUNDS Primary wounds from animal bites and missiles or others complicated by neglect must be considered individually. In general they may be surgically debrided and loosely approximated, thus allowing for drainage and preventing abscess formation while minimizing secondary healing. Specific microbiologic determinations are essential to any decision in the management of such cases. Regular oral hygiene and specific antibiotic therapy are helpful in achieving early healing.
BURNS AND IRRADIATION DEFECTS Delayed surgical treatment characterizes the management of this category of intraoral injury. It is almost impossible to evaluate accurately the extent of marginal viability of tissues in patients having just sustained an intraoral thermal or electrical burn, or when an ulcer has recently developed secondary to irradiation. Autogenous debridement is generally both superior and safer, compared to early surgical debridement, in this type of wound. The process of secondary healing progresses simultaneously with this autodebridement and, with the help of supportive treatment, a healed wound will usually result. In massive burns or extensive radiation ulcers, aggressive surgical debridement is indicated, but even in these instances reconstruction of the defect should be delayed because of the surgeon's inability, in most instances, to assess the depth and extent of injury accurately. After secondary healing is finally achieved, scar deformities commonly interfere with intraoral function, or even with the external appearance of the lips or cheeks. In such instances these scars can either be revised or, when extensive, resected and the defect reconstructed following the principles referred to above in the management of primary defects.
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
127
SUMMARY Intraoral wounds and surgical defects are analogous to similar cutaneous injuries, and with few exceptions should not be allowed to heal by secondary intention. Deformity and poor functioning scar tissue will usually result from failure to provide prompt intraoral continuity. The exceptions to this principle involve grossly contaminated wounds, bums, and irradiation ulcers, the management of which is briefly discussed. Four altemative methods of achieving intraoral coverage for surgical defects are presented. The three simpler and preferred methods are represented in drawings. The advantages of and indications for various types of suture material are discussed.
REFERENCES 1. Ballantyne, A. J.: The use of split thickness skin grafts in the surgical treatment of cancer of the mouth, hypopharynx, larynx and cervical esophagus. Amer. Surgeon, 27:315, 1961. 2. Conley, J. J.: The crippled oral cavity. Plast. Reconstr. Surg., 30:469, 1962. 3. Corso, P. F., and Gerold, F. P.: Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new technique. Amer. J. Surg., 104:731, 1962. 4. Des Prez, J. D., and Kiehn, C. L.: Methods of reconstruction following resection of anterior oral cavity and mandible for malignancy. Plast. Reconstr. Surg., 24:238, 1959. 5. Edgerton, M. T.: Use of lining flaps for repair of defects in oral mucosa. Cancer, 4:110, 1951. 6. Edgerton, M. T., and Des Prez, J.D.: Reconstruction of the oral cavity in the treatment of cancer. Plast. Reconstr. Surg. 19:89, 1957. 7. Gilles, H., and Millard, D. R.: The Principles and Art of Plastic Surgery. Boston, Little, Brown & Co., 1957, pp. 167, 345, 352, 512. 8. Guerrero-Santos: The tongue flap in reconstruction of the lip. Trans. 3rd Internat. Congr. of Plastic Surgery. Excerpt Medica Foundation International Congress Series No. 66, pp. 1055-1061. 9. Schultz, R. C.: Intraoral sutures. ].A.M.A., 195:No. 5, Jan., 1966. 3200 East Dempster Street Des Plaines, Illinois 60016
An erroneous axiom still persists in many reputable medical centers that defects within the mouth should be left to heal by themselves. This unfortunate philosophy may have had its origin in the observation that intraoral wounds and defects will close rapidly by epithelization. Unfortunately, uncontrolled and imprecise healing results in uncontrolled scarring and imprecise functions within the mouth just as it does anywhere else in the body. If a single principle is to be stated it should be: Repair intraoral wounds and defects by primary intention whenever possible. This paper will be primarily concerned with defects in the lining of the mouth and their reconstruction. Without attempting to be encyclopedic, a review of the causes of intraoral defects seems appropriate to introduce methods of reconstruction. The most common indication for intraoral reconstruction is trauma. Auto accidents account for most of these soft-tissue defects. These are commonly lacerations, avulsion flaps, and fractures of teeth, alveolus or bone, and usually require only debridement and primary repair. They should almost never be allowed to heal spontaneously. On the other hand, intraoral war wounds must be managed under different circumstances and often require delayed treatment and secondary reconstruction. Similar to this latter group are defects from animal bites, thermal burns, electrical burns, and radiation ulcers, all of which are usually managed with a plan for secondary reconstruction. The second most common indication for intraoral reconstruction is the presence of a defect resulting from tumor resection. 6 Such a defect, of course, may involve bone and muscle in addition to mucous membrane.
TRAUMA Intraoral lacerations and avulsion flaps are most often created by external forces causing shearing of the lips and cheeks over the *Clinical Assistant Professor of Surgery (Plastic), University of Illinois College of Medicine, Chicago, Illinois Surgical Clinics of North America- Vol. 48, No. 1, February, 1968
121
122
RICHARD
C.
SCHULTZ
teeth and supporting structures. The injuries are often completely through the lips or cheeks and can be associated with fractures of the teeth, dentures, alveolus, or supporting bone. These intraoral wounds should be repaired promptly, just as one approaches skin wounds. Often conditions do not permit the immediate reduction and fixation of the underlying fractures, but just as a surgeon attempts to achieve early primary closure of skin wounds, he should do the same within the mouth. In addition to minimizing secondary epithelization (scar), prompt repair covers exposed bone and fractures. 2 The choice of suture material within the mouth is worthy of discussion.3 Just as on the skin, nonabsorbable suture causes less tissue reaction and is probably more dependable relative to duration of holding power. On the other hand, absorbable material such as catgut is easy to work with in the mouth and does not usually require removal. This latter characteristic is especially advantageous in cases of children where suture removal may become a problem and may even interfere with the final result. If one chooses to use a nonabsorbable material, preference might be given to silk or one of the softer synthetic materials. Monofilament nylon is stiff and can prove uncomfortable within the mouth, possibly even cutting through the mucous membrane. In any case, a squedged-on needle reduces the trauma of suturing and simplifies suture handling.
SURGICAL DEFECTS As in trauma, prompt repair of elective surgical defects minimizes scarring and reduces morbidity. There is no good reason to permit a fresh surgical defect within the mouth to heal by secondary intention. Such defects usually result from the resection of intraoral malignant growths and are often created by the removal of adjacent teeth or bone resection. In such cases the availability of soft tissue for closure may actually become enhanced by the removal of bony contour, permitting a relatively simple closure of the surgical defect. Where this is not possible, epithelial closure should be planned, either by free grafts or local flaps. I. 4 • 5 Reconstruction by distant pedicle flaps is possible, but is timeconsuming and involves considerable preoperative planning and surgical preparation. 7 Such procedures should be reserved for major defects in which extensive underlying bone reconstruction is necessary. Figure 1 illustrates the use of a free split-thickness skin graft to close an intraoral defect involving the buccal mucosa, a portion of the posterior alveolus, and floor of the mouth. One should select a donor site which is minimally hair-bearing as such a characteristic may persist to some extent within the mouth. A skin graft may shrink and wrinkle for a time during its early phases of healing, but as it matures and adapts to its new location it usually becomes smooth once again and adopts a glistening mucoid surface. Figure 2 illustrates an alternate and, in many ways, an easier approach to reconstructing this same intraoral defect. This method utilizes
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
123
local adjacent tissue as a pedicle flap with primary closure of the donor site by undermining. The flap must be elevated without cutting it too thin but when properly planned and executed this method is exceedingly safe and dependable. Secondary surgical procedures are usually not necessary with this type of flap repair.
A ---- Surgical defect
B Cutting graft after outlining with template of defect
c Graft in place
4-0 silk over sponge rubber stent __ _ /
Figure 1. Reconstruction of mucosal defect with split-thickness skin graft. Graft should be of medium thickness and taken from a minimally hair-bearing area.
124
RICHARD
C.
SCHULTZ
c Flap outlined
D
E
Rotation of flap
Undermining mucosa
Figure 2. Reconstruction of mucosal defect with local pedicle flap. Flap should not be cut too thin and should be handled delicately. Intraoral sutures may be of either nonabsorbable or absorbable material.
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
125
The tongue has long been used to provide epithelial coverage within the mouth. It provides a marvelously movable donor site, making its use versatile. However, the surgeon must bear in mind that the tongue is a specialized organ and these functions should not be compromised for the sake of expediency. The tongue should not be used as a unit for side-to-side anastomosis
A
B Elevation of tongue flap
c
Tongue flap rotated and sutured into sal defect
D Division of pedicle two weeks later
Figure 3. Reconstruction of mucosal defect with pedicle flap from ventral surface of tongue. Pedicle flap is rotated 90 degrees into mucosal defect. Pedicle may subsequently be divided with aN o. 11 scalpel blade and revisions are seldom necessary.
126
RICHARD
C.
SCHULTZ
to provide closure for a defect in the mouth unless no other choice exists. Such a procedure may provide for initial healing, but cripples the function of the tongue, which can seldom be satisfactorily released. 3 Various flaps can nevertheless be taken from the tongue (without compromising its function) for ingenious reconstruction of defects about the mouth, including the vermilion of the lips. 8 The coarse, specialized epithelium of the dorsum of the tongue will undergo a metaplasia to adapt to the requirements of its new recipient site. Figure 3 illustrates a third alternative for reconstructing the same intraoral defect, using the tongue as a pedicle flap donor site. Such a procedure can be done under local anesthesia with minimal discomfort to the patient. The donor site is closed directly without difficulty. The tongue is tethered to the cheek by the pedicle of this flap for two to three weeks while healing at the periphery of the flap permits the development of an adequate blood supply. The limitation of function of the tongue during this period is surprisingly minimal. A simple division of the pedicle is then generally all that is necessary, and revisions are seldom indicated.
CONTAMINATED WOUNDS Primary wounds from animal bites and missiles or others complicated by neglect must be considered individually. In general they may be surgically debrided and loosely approximated, thus allowing for drainage and preventing abscess formation while minimizing secondary healing. Specific microbiologic determinations are essential to any decision in the management of such cases. Regular oral hygiene and specific antibiotic therapy are helpful in achieving early healing.
BURNS AND IRRADIATION DEFECTS Delayed surgical treatment characterizes the management of this category of intraoral injury. It is almost impossible to evaluate accurately the extent of marginal viability of tissues in patients having just sustained an intraoral thermal or electrical burn, or when an ulcer has recently developed secondary to irradiation. Autogenous debridement is generally both superior and safer, compared to early surgical debridement, in this type of wound. The process of secondary healing progresses simultaneously with this autodebridement and, with the help of supportive treatment, a healed wound will usually result. In massive burns or extensive radiation ulcers, aggressive surgical debridement is indicated, but even in these instances reconstruction of the defect should be delayed because of the surgeon's inability, in most instances, to assess the depth and extent of injury accurately. After secondary healing is finally achieved, scar deformities commonly interfere with intraoral function, or even with the external appearance of the lips or cheeks. In such instances these scars can either be revised or, when extensive, resected and the defect reconstructed following the principles referred to above in the management of primary defects.
INTRAORAL RECONSTRUCTION OF SOFT TISSUE DEFECTS
127
SUMMARY Intraoral wounds and surgical defects are analogous to similar cutaneous injuries, and with few exceptions should not be allowed to heal by secondary intention. Deformity and poor functioning scar tissue will usually result from failure to provide prompt intraoral continuity. The exceptions to this principle involve grossly contaminated wounds, bums, and irradiation ulcers, the management of which is briefly discussed. Four altemative methods of achieving intraoral coverage for surgical defects are presented. The three simpler and preferred methods are represented in drawings. The advantages of and indications for various types of suture material are discussed.
REFERENCES 1. Ballantyne, A. J.: The use of split thickness skin grafts in the surgical treatment of cancer of the mouth, hypopharynx, larynx and cervical esophagus. Amer. Surgeon, 27:315, 1961. 2. Conley, J. J.: The crippled oral cavity. Plast. Reconstr. Surg., 30:469, 1962. 3. Corso, P. F., and Gerold, F. P.: Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new technique. Amer. J. Surg., 104:731, 1962. 4. Des Prez, J. D., and Kiehn, C. L.: Methods of reconstruction following resection of anterior oral cavity and mandible for malignancy. Plast. Reconstr. Surg., 24:238, 1959. 5. Edgerton, M. T.: Use of lining flaps for repair of defects in oral mucosa. Cancer, 4:110, 1951. 6. Edgerton, M. T., and Des Prez, J.D.: Reconstruction of the oral cavity in the treatment of cancer. Plast. Reconstr. Surg. 19:89, 1957. 7. Gilles, H., and Millard, D. R.: The Principles and Art of Plastic Surgery. Boston, Little, Brown & Co., 1957, pp. 167, 345, 352, 512. 8. Guerrero-Santos: The tongue flap in reconstruction of the lip. Trans. 3rd Internat. Congr. of Plastic Surgery. Excerpt Medica Foundation International Congress Series No. 66, pp. 1055-1061. 9. Schultz, R. C.: Intraoral sutures. ].A.M.A., 195:No. 5, Jan., 1966. 3200 East Dempster Street Des Plaines, Illinois 60016