Flap necrosis after palatoplasty in irradiated patient and its reconstruction with tunnelized-facial artery myomucosal island flap
© The Author(s). 2017
Received: 21 June 2017
Accepted: 12 July 2017
Published: 25 August 2017
Tunneled transposition of the facial artery myomucosal (FAMM) island flap on the lingual side of the mandible has been reported for intraoral as well as oropharyngeal reconstruction. This modified technique overcomes the limitations of short range and dentition and further confirms the flexibility of the flap. This paper presents a case of reconstructing secondary soft palatal defect due to flap necrosis following two-flap palatoplasty in irradiated patient with lingually transposed facial artery myomucosal island flap.
The authors successfully reconstructed secondary soft palatal defect due to flap necrosis following two-flap palatoplasty in an irradiated 59-year-old female patient with tunnelized-facial artery myomucosal island flap (t-FAMMIF).
Islanding and tunneling modification extends the versatility of the FAMM flap in the reconstruction of soft palatal defects post tumor excision and even after radiation, giving a great range of rotation and eliminating the need for revision in a second stage procedure. The authors thus highly recommend this versatile flap for the reconstruction of small and medium-sized oral defects.
Depending on the site and size of the defect, fasciocutaneous free flaps [1–4], locoregional pedicled flaps [5, 6], and local flaps [7–9] can be used to reconstruct soft palatal defects following tumor resection to prevent nasal speech with excessive air escape and nasal regurgitation of food. Among these, buccinator-based myomucosal or facial artery myomucosal (FAMM) flaps are rich in blood supply, have appropriate thickness and considerable mucosal paddle , and can secrete saliva; hence, they are good choices for the repair of intraoral medium-sized mucosal defects .
Pribaz et al. described the many advantages of the FAMM flap over flaps based on the buccal artery, including the greater versatility in reconstructing a wide range of difficult intraoral problems for which conventional techniques have failed . The FAMM island flap was recently popularized by Zhao et al., who also described a myomucosal island flap (BUMIF, buccinator myomucosal island flap) for use in cases of cleft palate and periorbital defects . As a disadvantage of these flaps, shortage of range may occur when covering contralateral defects in the floor of the mouth and gingiva, particularly in dentate patients. Tunneled transposition of the FAMM island flap on the lingual side of the mandible has been reported for intraoral as well as oropharyngeal reconstruction. This technique overcomes the limitations of short range and dentition and further confirms the flexibility of the flap [7, 8, 14–16]. We used this flap for the first time in 2013 for reconstruction of palatomaxillary defect . This paper presents another case of reconstructing secondary soft palatal defect due to flap necrosis following two-flap palatoplasty in irradiated patient with a lingually transposed facial artery myomucosal island flap.
Reconstruction of maxillofacial defects lets surgeon find the most satisfactory flap both esthetically and functionally. It requires not just a knowledge of the flap, but an ability to think and plan in three dimensions . In particular, it is physiologically optimal and advantageous to reconstruct oral mucosa with the same kind of tissue . Though microsurgery has advanced greatly, the morbidity of the donor site, extended surgery, and longer hospitalization constitute limitations when applying this surgical method to patients with poor health. Thus, the defect, when smaller than 8–10 cm, can be reconstructed properly with local or locoregional flaps .
Since it was introduced by Janusz Bardach in 1967, two-flap palatoplasty remains a highly successful technique for closure of a variety of palatal clefts, with low fistula incidence  and yielding excellent surgical and speech outcomes . We therefore decided to apply this technique to closing the fistula with the consent of the patient although the patient had had postoperative radiotherapy. However, poor blood circulation in the right descending palatal artery intraoperatively eventually led to the right palatal flap becoming necrotized. When deciding the next relief surgery, we considered free flap (radial forearm) or local flap (FAMM flap) and chose local flap on the principle of replacing like with like . In contrast to reconstruction with the FAMM flap, which has traditionally been described as a two-stage procedure , this modification by tunneling on the lingual side of the mandible made the operation more simple and versatile [7, 23, 24].
The facial artery was easily identified and preserved with a Doppler probe. Without a 2-team approach, the flap was easily harvested and tunneled submandibularly on the lingual side of the mandible and finally transposed to the defect site and sutured. In Fig. 4 (bottom left), the flap showed some degree of venous congestion immediate postoperatively, but became resolved in a few days with adequate venous drainage provided by submucosal plexus . The donor site was covered with buccal fat pad advancement. As seen in Fig. 4 (bottom right), the flap shows an excellent color match with recipient tissue.
HIJ, HMC, JYP, YHC, and HJK participated in this operation and are responsible for the data collection, drafting the article, and the critical revision of the article. WN is responsible for the conception and design of the study, the critical revision of the article, and the approval of the article. All authors read and approved the final manuscript.
Hye-In Jeong: DDS, Resident at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (YSJHICD@yuhs.ac).
Hye-Min Cho: DDS, Resident at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (ASHCHM7@yuhs.ac).
Jongyeol Park: DDS, Resident at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (HHPJY@yuhs.ac).
Yong-Hoon Cha: DDS, PhD, Clinical research fellow at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (firstname.lastname@example.org).
Hyung Jun Kim: DDS, PhD, Professor at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (email@example.com).
Corresponding Author - Woong Nam: DDS, PhD, Professor at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (firstname.lastname@example.org).
Ethics approval and consent to participate
The study was approved by the institutional review board of Yonsei Dental Hospital (IRB approval number 2-2017-0021).
The authors alone are responsible for the content and writing of the article. The authors declare that they have no competing interests.
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