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The temporal muscle flap for closure of large palatal defects in CLP patients
Reconstructivesurgery
The temporal muscle flap for closure of large palatal defects in CLP patients
K. G. H. v a n d e r Wal 1, J. W. M u l d e r 2 Departments of 1Oral and Maxillofacial Surgery and 2Plastic Surgery, Medisch Centrum Leeuwarden, The Netherlands
K. G. H. van der Wal, J. W. Mulder: The temporal muscle flap Jor closure of large palatal defects in CLP patients. Int. J. Oral Maxillofac. Surg. 1992; 21: 3-5. Abstract. Large palatal defects in 4 CLP patients were successfully closed by transposition of the anterior part of the temporal muscle. The donor side was filled by transposing the posterior part of the temporal muscle whilst the posterior area was contoured with orthopaedic bone cement.
The closure of large palatal defects in cleft lip and palate (CLP) patients is difficult and residual openings are sometimes unavoidable. In spite of prosthetic rehabilitation, patients may still experience leakage through the nose while drinking, whilst nasal speech is not uncommon in such patients. The standard treatment for closure of such residual palatal defects is transposition of mucoperiostal flaps; however this tends to fail in patients who have large palatal defects with scarring from previous operations. Various tissue transfers have also been used, such as the tongue flap 1, the pedicle flap from the inner, hairless, suface of the arm 6, the free radial forearm flap and the temporal muscle flap 2-5,7 12. The tongue flap and the pedicle flap of the arm are likely to present an inconvenience to the patient. In addition, the
bulky, irregular, surface of the tongue mucosa is not suitable to support a dental prosthesis, while the forearm flap carries a risk of thrombosis and may produce disfiguring scars on the forearm and the face. The temporal muscle flap is not too bulky, has a reliable blood supply, and is the authors' choice for repair of large palatal defects. The temporal muscle spreads broadly on the side of the skull, except where its fibres converge towards the tendon of its insertion. It arises from the temporal fossa and inserts on the deep surface of the coronoid process and the anterior border of the mandibular ascending ramus. The muscle is supplied by the deep temporal artery, a branch of the maxillary artery, which divides into an anterior and posterior branch. The temporal muscle is innervated by
Key words: cleft lip and palate; palatal de-
fects; temporal muscle flap. Accepted for publication 21 September 1991
the anterior and posterior deep temporal nerves and, if present, a middle temporal nerve. These nerves are branches of the mandibular nerve.
M a t e r i a l and m e t h o d s
In an 11-year period (1980-1990) 16 ~atients (3 3 and 13 ~; mean age 49.1 years, 33-66 years) were treated for palatal defects related to CLR In 10 patients a transposition of mucoperiostal flaps was carried out and in one patient a tongue flap was used. In one patient a free radial forearm flap and in 4 patients a temporal muscle flap was utilized. The 4 patients treated with temporal muscle flaps were treated under general anaesthesia. The temporal muscle was exposed using a hemicoronal incision with a preauricular extension, the incision being made into the subgaleal level. The temporal muscle was mobilised subperiostally from its deep origin
b Fig. la. Division of the temporal muscle according to the vascular supply. Fig. lb. The anterior part of the temporal muscle is transposed to the oral cavity and the posterior part is rotated forward.
4
van der Wal a n d M u l d e r
Fig. 2a. Preoperative view of the palatal defect. Fig. 2b. The temporal muscle in position. Fig. 2c. Epithelialisation of the temporal muscle and closure of the defect, shown 3 months postoperatively.
in the temporal fossa, anteriorly to the lateral aspect of the orbit and descending to the temporal crest. Particular care was given to preserving the blood supply. The temporal muscle was divided into an anterior and posterior section according to its vascular supply (Fig. 1), The zygomatic arch was exposed and divided as far forward and posteriorly as possible to allow the temporal muscle to be rotated into the oral cavity. A bone tunnel through the maxilla into the oral cavity was created using a rongeur. This tunnel runs from the region of the zygomatic arch, passes through t h e posterior lateral maxillary wall into the palatal defect. If teeth were present the entrance of the bone tunnel was kept 5
mm above and behind the molar roots. If a 3rd molar was present, it was removed. The palatal defect was closed in 2 layers as follows: an incision was made around the palatal defect and the mucosa mobilised and inverted towards the nasal cavity and sutured without tension. The anterior part of the temporal muscle was then pulled through the tunnel created and sutured to the palatal surface of the inverted mucosa. The divided zygomatic arch was repositioned and fixed with intraosseous wires. The posterior part of the temporal muscle was rotated forward and sutured to the calvarial periosteum and the contour defect filled with orthopaedic bone cement. The hemico-
Table 1. Clinical data of 4 CLP patients, with large palatal defects and extensive scarring as a result of previous operations, treated with a temporal muscle flap
1 2 3 4
Age Gender
Operation time
Blood loss
Follow up period
58 9 58 9 56 9 40
3 hours 50 min 2 hours 55 min 3 hours 10 min 3 hours 5 min
150 cc
1.4 year
200 cc
2.8 years
100 cc
2.6 years
600 cc
3.0 years
years years years years
ronal flap was repositioned, a drain placed and the incision closed in layers (Fig. 2). When a velopharyngeal incompetence exists, this procedure can be combined with a pharyngoplasty using a superiorly based pharyngeal flap. Antimicrobial prophylaxis consisted of Amoxicilline 500 mg, 3 x per 24 h during 5 days. The patient also received Dexamethason 4 mg, 4 x per 24 h the first day, which was gradually tapered offover a 4-day period. Calciumheparine 0.2 ml was administered subcutaneously b.i.d, until the patient was mobilized.
Results The results o f the 4 patients treated with the t e m p o r a l muscle flap are s h o w n in Table 1. In all 4 patients the large palatal defects were closed in 2 layers, including the inverted palatal m u c o s a a n d the t e m p o r a l muscle flap. The posterior p a r t o f the t e m p o r a l muscle flap was r o t a t e d f o r w a r d s and the remaining space filled with o r t h o p a e d i c b o n e cem e n t (Palakos®), which gave excellent cosmetic results. In Case 2, the t e m p o r a l muscle flap was used in c o n j u n c t i o n with a superiorly based pharyngeal flap. N o n e o f
Temporal muscle.flap for closure of" large palatal defects in CLP patients the patients had signs of velopharyngeal incompetence as confirmed on examination by a speech pathologist.
Discussion
The temporal muscle flap has proven to be a reliable flap in reconstructive surgery of the maxillofacial area. This is particularly true for closure of large defects in the maxilla 2'3,4,7,11'12. The dissection is relatively easy to carry out and does not leave an unsightly scar or defect. The blood supply of the temporal muscle appears to be adequate even after rotation, provided the 2 main branches are not severed during surgery. Since epithelialisation takes place in about 3 to 4 weeks 4'5 the intra-orally, exposed part of the temporal muscle flap does not require a split skin or nqucosal graft. Reconstruction of the hard palate using the temporal muscle flap, provided an adequate alveolar process is present, gives functionally acceptable results (5). Dentures can easily be constructed for these patients. The scar of the hemicoronal incision with the preauricular extension is usually cosmetically acceptable. The use of implant material to fill up the temporal defect gives excellent results in that no un-
aesthetic depressions are left behind (10). In conclusion, for closure of large palatal defects in adult C L P patients, the authors prefer the temporal muscle flap 12. Smaller defects are probably best treated with local transposition flaps or small tongue flaps. The procedure described is safe and presents good results, especially for patients with extensive scars from previous operations. References
l. ARGAMASORV. The tongue flap: placement and fixation for closure of postpalatoplasty fistulae. Cleft J 1990: 27: 402-10. 2. BAKAMJIAMV. A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Hast Reconstr Surg 1963: 31: 103-17. 3. BAKAnAMVY, SOUTHERSG. Use of the temporal muscle for reconstruction after orbito-maxillary resections for cancer. Hast Reconstr Surg 1975: 56: 171-7. 4. BRADLEYP, BROCKBANKJ. The temporal muscle in oral reconstruction. J Maxillofac Surg 1981: 9:139 45. 5. DEMASPN, SOTEREANOSGC. Transmaxillary temporalis transfer for reconstruction of a large palatal defect: report of a case. J Oral Maxillofac Surg 1989: 47: 197 202. 6. DIECKMANNJ, BONING K. Zwischenkieferverlust und seine Deckung durch Oberarmrundstiellappen. Fortschr Kiefer Ges-
5
ichtschir Bd XXII. Stuttgart: Thieme, 1978: 1124. 7. HABEL G. Zur Deckung intraoraler Defekte nach radikal operierten Mundh6hlenkarzinomen. Dtsch Z Mund Kiefer Gesichtschir 1984: 8:405 10. 8. HAUELG, HENSCHERR. The versatility of the temporal muscle flap in reconstructive surgery. Br J Oral Maxillofac Surg 1986: 24:96 101. 9. MACLEODAM, MORISSONWA, MCCANN JJ, THISTLETHWAITES, VAN DER KOLK CA, RYAN AD. The free radial forearm flap with and without bone for closure of large palatal fistulae. Br J Plast Surg 1987: 40:391 5. 10. PmLHPS JG, PECKITT NS. Reconstruction of the palate using bilateral temporalis muscle flap: a case report. Br J Oral Maxillofac Surg 1988: 26: 322-5. 11. Vov ED. Temporalismuskel-bilobed flap zur Deckung grosser zentraler Oberkieferdefekte. Dtsch Z Mund Kiefer Gesichtschir 1986: 10: 433-5. 12. VAN DER WAL KGH, MULDER JW. Het sluiten van centrale palatum defecten met de musculus temporalis-lap. Ned Tijdschr Geneesk 1990: 134:538 40.
Address: Dr. K. G. H. van der Wal Department of Oral and Maxillofacial Surgery Medisch Centrum Leeuwarden Henri Dunantweg 2 8934 AD, Leeuwarden The Netherlands
The temporal muscle flap for closure of large palatal defects in CLP patients
K. G. H. v a n d e r Wal 1, J. W. M u l d e r 2 Departments of 1Oral and Maxillofacial Surgery and 2Plastic Surgery, Medisch Centrum Leeuwarden, The Netherlands
K. G. H. van der Wal, J. W. Mulder: The temporal muscle flap Jor closure of large palatal defects in CLP patients. Int. J. Oral Maxillofac. Surg. 1992; 21: 3-5. Abstract. Large palatal defects in 4 CLP patients were successfully closed by transposition of the anterior part of the temporal muscle. The donor side was filled by transposing the posterior part of the temporal muscle whilst the posterior area was contoured with orthopaedic bone cement.
The closure of large palatal defects in cleft lip and palate (CLP) patients is difficult and residual openings are sometimes unavoidable. In spite of prosthetic rehabilitation, patients may still experience leakage through the nose while drinking, whilst nasal speech is not uncommon in such patients. The standard treatment for closure of such residual palatal defects is transposition of mucoperiostal flaps; however this tends to fail in patients who have large palatal defects with scarring from previous operations. Various tissue transfers have also been used, such as the tongue flap 1, the pedicle flap from the inner, hairless, suface of the arm 6, the free radial forearm flap and the temporal muscle flap 2-5,7 12. The tongue flap and the pedicle flap of the arm are likely to present an inconvenience to the patient. In addition, the
bulky, irregular, surface of the tongue mucosa is not suitable to support a dental prosthesis, while the forearm flap carries a risk of thrombosis and may produce disfiguring scars on the forearm and the face. The temporal muscle flap is not too bulky, has a reliable blood supply, and is the authors' choice for repair of large palatal defects. The temporal muscle spreads broadly on the side of the skull, except where its fibres converge towards the tendon of its insertion. It arises from the temporal fossa and inserts on the deep surface of the coronoid process and the anterior border of the mandibular ascending ramus. The muscle is supplied by the deep temporal artery, a branch of the maxillary artery, which divides into an anterior and posterior branch. The temporal muscle is innervated by
Key words: cleft lip and palate; palatal de-
fects; temporal muscle flap. Accepted for publication 21 September 1991
the anterior and posterior deep temporal nerves and, if present, a middle temporal nerve. These nerves are branches of the mandibular nerve.
M a t e r i a l and m e t h o d s
In an 11-year period (1980-1990) 16 ~atients (3 3 and 13 ~; mean age 49.1 years, 33-66 years) were treated for palatal defects related to CLR In 10 patients a transposition of mucoperiostal flaps was carried out and in one patient a tongue flap was used. In one patient a free radial forearm flap and in 4 patients a temporal muscle flap was utilized. The 4 patients treated with temporal muscle flaps were treated under general anaesthesia. The temporal muscle was exposed using a hemicoronal incision with a preauricular extension, the incision being made into the subgaleal level. The temporal muscle was mobilised subperiostally from its deep origin
b Fig. la. Division of the temporal muscle according to the vascular supply. Fig. lb. The anterior part of the temporal muscle is transposed to the oral cavity and the posterior part is rotated forward.
4
van der Wal a n d M u l d e r
Fig. 2a. Preoperative view of the palatal defect. Fig. 2b. The temporal muscle in position. Fig. 2c. Epithelialisation of the temporal muscle and closure of the defect, shown 3 months postoperatively.
in the temporal fossa, anteriorly to the lateral aspect of the orbit and descending to the temporal crest. Particular care was given to preserving the blood supply. The temporal muscle was divided into an anterior and posterior section according to its vascular supply (Fig. 1), The zygomatic arch was exposed and divided as far forward and posteriorly as possible to allow the temporal muscle to be rotated into the oral cavity. A bone tunnel through the maxilla into the oral cavity was created using a rongeur. This tunnel runs from the region of the zygomatic arch, passes through t h e posterior lateral maxillary wall into the palatal defect. If teeth were present the entrance of the bone tunnel was kept 5
mm above and behind the molar roots. If a 3rd molar was present, it was removed. The palatal defect was closed in 2 layers as follows: an incision was made around the palatal defect and the mucosa mobilised and inverted towards the nasal cavity and sutured without tension. The anterior part of the temporal muscle was then pulled through the tunnel created and sutured to the palatal surface of the inverted mucosa. The divided zygomatic arch was repositioned and fixed with intraosseous wires. The posterior part of the temporal muscle was rotated forward and sutured to the calvarial periosteum and the contour defect filled with orthopaedic bone cement. The hemico-
Table 1. Clinical data of 4 CLP patients, with large palatal defects and extensive scarring as a result of previous operations, treated with a temporal muscle flap
1 2 3 4
Age Gender
Operation time
Blood loss
Follow up period
58 9 58 9 56 9 40
3 hours 50 min 2 hours 55 min 3 hours 10 min 3 hours 5 min
150 cc
1.4 year
200 cc
2.8 years
100 cc
2.6 years
600 cc
3.0 years
years years years years
ronal flap was repositioned, a drain placed and the incision closed in layers (Fig. 2). When a velopharyngeal incompetence exists, this procedure can be combined with a pharyngoplasty using a superiorly based pharyngeal flap. Antimicrobial prophylaxis consisted of Amoxicilline 500 mg, 3 x per 24 h during 5 days. The patient also received Dexamethason 4 mg, 4 x per 24 h the first day, which was gradually tapered offover a 4-day period. Calciumheparine 0.2 ml was administered subcutaneously b.i.d, until the patient was mobilized.
Results The results o f the 4 patients treated with the t e m p o r a l muscle flap are s h o w n in Table 1. In all 4 patients the large palatal defects were closed in 2 layers, including the inverted palatal m u c o s a a n d the t e m p o r a l muscle flap. The posterior p a r t o f the t e m p o r a l muscle flap was r o t a t e d f o r w a r d s and the remaining space filled with o r t h o p a e d i c b o n e cem e n t (Palakos®), which gave excellent cosmetic results. In Case 2, the t e m p o r a l muscle flap was used in c o n j u n c t i o n with a superiorly based pharyngeal flap. N o n e o f
Temporal muscle.flap for closure of" large palatal defects in CLP patients the patients had signs of velopharyngeal incompetence as confirmed on examination by a speech pathologist.
Discussion
The temporal muscle flap has proven to be a reliable flap in reconstructive surgery of the maxillofacial area. This is particularly true for closure of large defects in the maxilla 2'3,4,7,11'12. The dissection is relatively easy to carry out and does not leave an unsightly scar or defect. The blood supply of the temporal muscle appears to be adequate even after rotation, provided the 2 main branches are not severed during surgery. Since epithelialisation takes place in about 3 to 4 weeks 4'5 the intra-orally, exposed part of the temporal muscle flap does not require a split skin or nqucosal graft. Reconstruction of the hard palate using the temporal muscle flap, provided an adequate alveolar process is present, gives functionally acceptable results (5). Dentures can easily be constructed for these patients. The scar of the hemicoronal incision with the preauricular extension is usually cosmetically acceptable. The use of implant material to fill up the temporal defect gives excellent results in that no un-
aesthetic depressions are left behind (10). In conclusion, for closure of large palatal defects in adult C L P patients, the authors prefer the temporal muscle flap 12. Smaller defects are probably best treated with local transposition flaps or small tongue flaps. The procedure described is safe and presents good results, especially for patients with extensive scars from previous operations. References
l. ARGAMASORV. The tongue flap: placement and fixation for closure of postpalatoplasty fistulae. Cleft J 1990: 27: 402-10. 2. BAKAMJIAMV. A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Hast Reconstr Surg 1963: 31: 103-17. 3. BAKAnAMVY, SOUTHERSG. Use of the temporal muscle for reconstruction after orbito-maxillary resections for cancer. Hast Reconstr Surg 1975: 56: 171-7. 4. BRADLEYP, BROCKBANKJ. The temporal muscle in oral reconstruction. J Maxillofac Surg 1981: 9:139 45. 5. DEMASPN, SOTEREANOSGC. Transmaxillary temporalis transfer for reconstruction of a large palatal defect: report of a case. J Oral Maxillofac Surg 1989: 47: 197 202. 6. DIECKMANNJ, BONING K. Zwischenkieferverlust und seine Deckung durch Oberarmrundstiellappen. Fortschr Kiefer Ges-
5
ichtschir Bd XXII. Stuttgart: Thieme, 1978: 1124. 7. HABEL G. Zur Deckung intraoraler Defekte nach radikal operierten Mundh6hlenkarzinomen. Dtsch Z Mund Kiefer Gesichtschir 1984: 8:405 10. 8. HAUELG, HENSCHERR. The versatility of the temporal muscle flap in reconstructive surgery. Br J Oral Maxillofac Surg 1986: 24:96 101. 9. MACLEODAM, MORISSONWA, MCCANN JJ, THISTLETHWAITES, VAN DER KOLK CA, RYAN AD. The free radial forearm flap with and without bone for closure of large palatal fistulae. Br J Plast Surg 1987: 40:391 5. 10. PmLHPS JG, PECKITT NS. Reconstruction of the palate using bilateral temporalis muscle flap: a case report. Br J Oral Maxillofac Surg 1988: 26: 322-5. 11. Vov ED. Temporalismuskel-bilobed flap zur Deckung grosser zentraler Oberkieferdefekte. Dtsch Z Mund Kiefer Gesichtschir 1986: 10: 433-5. 12. VAN DER WAL KGH, MULDER JW. Het sluiten van centrale palatum defecten met de musculus temporalis-lap. Ned Tijdschr Geneesk 1990: 134:538 40.
Address: Dr. K. G. H. van der Wal Department of Oral and Maxillofacial Surgery Medisch Centrum Leeuwarden Henri Dunantweg 2 8934 AD, Leeuwarden The Netherlands