- Case report
- Open Access
Flap necrosis after palatoplasty in irradiated patient and its reconstruction with tunnelized-facial artery myomucosal island flap
Maxillofacial Plastic and Reconstructive Surgery volume 39, Article number: 24 (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 [1,2,3,4], locoregional pedicled flaps [5, 6], and local flaps [7,8,9] 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, 14,15,16]. 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.
A 59-year-old female patient visited our oral and maxillofacial department clinic complaining of a sense of discomfort in the right posterior palatal area. The patient did not remember exactly when the symptom began. The patient had no other concerned medical history. On clinical examination, a dome-shaped mass of 2.0 × 2.5 × 1.0 cm with clear border and no ulceration was observed in the right posterior palatal area. On the next days of admission, incisional biopsy was performed under local anesthesia. Pleomorphic adenoma (with central coagulative necrosis, most likely traumatized pleomorphic adenoma) was reported histopathologically. Hence, the patient underwent simple mass excision with safety margin under general anesthesia without any additional examination (Fig. 1). Postoperative histopathologic report was epithelial myoepithelial carcinoma with positive basal resection margin. Magnetic resonance imaging of the head and neck and whole-body positron emission tomography were performed for further examination, but there was no evidence of distant metastasis (pT2N0M0, stage II) that was shown (Fig. 2). Postoperative radiation therapy was administered to the primary site at the Department of Radiation Oncology, and the total radiation dose was 6148, 5400, and 4500 cGy at the operation site, border area, and lateral cervical lymph node level IB and II, respectively, for 39 days. There were no significant complications other than oral mucositis.
After radiation therapy, a 1.5 × 1.0 cm fistula occurred in the right site, which was the operated site, and a fistula closure was done using two-flap palatoplasty under general anesthesia at 8 months after radiation therapy. However, the operated right side flap, which had poor blood circulation after radiation therapy, was necrotized (Fig. 3). We removed the necrotized flap under general anesthesia and designed a facial artery myomucosal island flap containing the right mucosal membrane and buccinators, using the facial artery as a trophic blood supply to the flap. The flap was transposed by tunneling to restore the defect through the lingual side of the mandible. The donor was restored using the ipsilateral buccal fat pad flap. After the operation, the nasal and oral opening was closed and properly healed up (Fig. 4).
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.
This flap provides an abundant source of local tissue like buccinator muscle and may be reinnervated by the recipient site motor nerve, and the mucosa with connective and glandular tissue, which retains the secretory function of the native soft palate . It is also advantageous that the flap is hairless and more pliable than a skin flap. It is known that no radiotherapy-associated shrinking has been observed . The following are some basic precautions: first, care must be taken to preserve the Stensen duct, the orifice of which must be identified and preserved during flap harvesting. Second, avoid damage to the marginal mandibular branch of the facial nerve during tunneling. Identify the course of the nerve with a nerve stimulator. Third, confirm if there is a neck lymph node metastasis because facial vessel dissection may impair the oncologic safety (the presence of lymph node metastasis is a contraindication for the use of this flap). Fourth, check the postoperative mouth opening. Trismus may occur as a result of buccinator harvesting, but can be avoided with active postoperative mouth opening exercise. Finally, although there are several terms for buccinator‑based myomucosal flaps such as Bozola flap, Zhao flap, FAMM flap, BUMMIF, myomucosal cheek flap, buccal musculomucosal flap, buccal mucosal transposition flap, and intraoral cheek transposition flap, the author coined the term “tunnelized-Facial Myo-Mucosal Island Flap (t-FAMMIF)” because this modified flap is meant to be used for more innovative purposes than traditional methods are intended (Fig. 5) . The authors highly recommend this flap to oral and maxillofacial surgeons who treat oral cancer patients as it may be widely used in reconstruction during initial stages of oral cancer due to the recent advent of early diagnosis.
Moubayed SP, Osorio M, Buchbinder D, Lazarus C, Urken ML (2017) Soft palate reconstruction using a combination of a turn-in flap and a radial forearm flap. Laryngoscope. doi:10.1002/lary.26462
Hamahata A, Beppu T, Tokumaru T, Yamaki T, Sakurai H (2017) A comparison of large soft palate defect reconstruction using the new “tunnel structure” and traditional “port structure” methods. J Reconstr Microsurg 33(1):70–76
Pauchot J, Feuvrier D, Pluvy I, Floret F, Mauvais O (2016) An original “double-arched” radial forearm flap for soft palate reconstruction. Case report. Ann Chir Plast Esthet 61(6):892–895
Miyamoto S, Sakuraba M, Nagamatsu S, Fujiki M, Fukunaga Y, Hayashi R (2016) Combined use of anterolateral thigh flap and pharyngeal flap for reconstruction of extensive soft-palate defects. Microsurgery 36(4):291–296
Meccariello G, Montevecchi F, Deganello A, D'Agostino G, Bellini C, Zeccardo E et al (2016) The temporalis muscle flap for reconstruction of soft palate and lateral oropharyngeal wall after transoral robotic surgery. Auris Nasus Larynx (2017) https://doi.org/10.1016/j.anl.2016.11.011
Mai JP, Sadeghi N (2015) Pharyngeal tube flap and palatoglossal rotation flap in subtotal soft palate reconstruction. Otolaryngol Head Neck Surg 153(4):688–690
Frisch T (2017) Versatility of the facial artery myomucosal island flap in neopharyngeal reconstruction. Head Neck 39(2):E29–E33
Khan K, Hinckley V, Cassell O, Silva P, Winter S, Potter M (2013) A novel use of the facial artery based buccinator musculo-mucosal island flap for reconstruction of the oropharynx. J Plast Reconstr Aesthet Surg 66(10):1365–1368
Massarelli O, Gobbi R, Soma D, Tullio A (2013) The folded tunnelized-facial artery myomucosal island flap: a new technique for total soft palate reconstruction. J Oral Maxillofac Surg 71(1):192–198
Ferrari S, Copelli C, Bianchi B, Ferri A, Sesenna E (2012) The Bozola flap in oral cavity reconstruction. Oral Oncol 48(4):379–382
Joshi A, Rajendraprasad JS, Shetty K (2005) Reconstruction of intraoral defects using facial artery musculomucosal flap. Br J Plast Surg 58(8):1061–1066
Pribaz J, Stephens W, Crespo L, Gifford G (1992) A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 90(3):421–429
Zhao Z, Li S, Yan Y, Li Y, Yang M, Mu L et al (1999) New buccinator myomucosal island flap: anatomic study and clinical application. Plast Reconstr Surg 104(1):55–64
Massarelli O, Baj A, Gobbi R, Soma D, Marelli S, De Riu G et al (2013) Cheek mucosa: a versatile donor site of myomucosal flaps. Technical and functional considerations. Head Neck 35(1):109–117
Ferrari S, Balestreri A, Bianchi B, Multinu A, Ferri A, Sesenna E (2008) Buccinator myomucosal island flap for reconstruction of the floor of the mouth. J Oral Maxillofac Surg 66(2):394–400
Bianchi B, Ferri A, Ferrari S, Copelli C, Sesenna E (2009) Myomucosal cheek flaps: applications in intraoral reconstruction using three different techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108(3):353–359
Da Jung Ryu HWJ, Park HJ, Kim HJ, Cha I-H, Nam W (2013) Tunnelized-facial artery myomucosal island flap (t-FAMMIF) for palatomaxillary reconstruction: a report of two cases. J Korean Assoc Maxillofac Plast Reconstr Surg 35(2):100–106
Jackson IT (1997) Local flap reconstruction of defects after excision of nonmelanoma skin cancer. Clin Plast Surg 24(4):747–767
Shipkov H, Stefanova P, Hadjiev B, Uchikov A, Djambazov K, Mojallal A (2011) The posterior-based buccinator myomucosal flap for palatal defects. J Oral Maxillofac Surg 69(5):1265–1266, author reply 1266
Ferrari S, Ferri A, Bianchi B, Copelli C, Magri AS, Sesenna E (2009) A novel technique for cheek mucosa defect reconstruction using a pedicled buccal fat pad and buccinator myomucosal island flap. Oral Oncol 45(1):59–62
Murthy AS, Parikh PM, Cristion C, Thomassen M, Venturi M, Boyajian MJ (2009) Fistula after 2-flap palatoplasty: a 20-year review. Ann Plast Surg 63(6):632–635
Salyer KE, Sng KW, Sperry EE (2006) Two-flap palatoplasty: 20-year experience and evolution of surgical technique. Plast Reconstr Surg 118(1):193–204
Joseph ST, Naveen BS, Mohan TM (2017) Islanded facial artery musculomucosal flap for tongue reconstruction. Int J Oral Maxillofac Surg 46(4):453–455
Bardazzi A, Beltramini GA, Autelitano L, Bazzacchi R, Rabbiosi D, Pedrazzoli M et al (2017) Use of buccinator myomucosal flap in tongue reconstruction. J Craniofac Surg 28(4):1084–1087
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 (email@example.com).
Hyung Jun Kim: DDS, PhD, Professor at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (firstname.lastname@example.org).
Corresponding Author - Woong Nam: DDS, PhD, Professor at Oral and Maxillofacial Surgery, Yonsei University, College of Dentistry, Seoul, Korea (email@example.com).
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.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Jeong, H., Cho, H., Park, J. et al. Flap necrosis after palatoplasty in irradiated patient and its reconstruction with tunnelized-facial artery myomucosal island flap. Maxillofac Plast Reconstr Surg 39, 24 (2017) doi:10.1186/s40902-017-0121-5