- Case report
- Open Access
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 (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.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- 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):70–76PubMedGoogle Scholar
- 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):892–895View ArticlePubMedGoogle Scholar
- 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):291–296View ArticlePubMedGoogle Scholar
- 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):688–690View ArticlePubMedGoogle Scholar
- Frisch T (2017) Versatility of the facial artery myomucosal island flap in neopharyngeal reconstruction. Head Neck 39(2):E29–E33View ArticlePubMedGoogle Scholar
- 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):1365–1368View ArticlePubMedGoogle Scholar
- 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):192–198View ArticlePubMedGoogle Scholar
- Ferrari S, Copelli C, Bianchi B, Ferri A, Sesenna E (2012) The Bozola flap in oral cavity reconstruction. Oral Oncol 48(4):379–382View ArticlePubMedGoogle Scholar
- Joshi A, Rajendraprasad JS, Shetty K (2005) Reconstruction of intraoral defects using facial artery musculomucosal flap. Br J Plast Surg 58(8):1061–1066View ArticlePubMedGoogle Scholar
- Pribaz J, Stephens W, Crespo L, Gifford G (1992) A new intraoral flap: facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 90(3):421–429View ArticlePubMedGoogle Scholar
- 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):55–64View ArticlePubMedGoogle Scholar
- 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):109–117View ArticlePubMedGoogle Scholar
- 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):394–400View ArticlePubMedGoogle Scholar
- 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):353–359View ArticlePubMedGoogle Scholar
- 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):100–106Google Scholar
- Jackson IT (1997) Local flap reconstruction of defects after excision of nonmelanoma skin cancer. Clin Plast Surg 24(4):747–767PubMedGoogle Scholar
- 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 1266View ArticlePubMedGoogle Scholar
- 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):59–62View ArticlePubMedGoogle Scholar
- 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):632–635View ArticlePubMedGoogle Scholar
- Salyer KE, Sng KW, Sperry EE (2006) Two-flap palatoplasty: 20-year experience and evolution of surgical technique. Plast Reconstr Surg 118(1):193–204View ArticlePubMedGoogle Scholar
- Joseph ST, Naveen BS, Mohan TM (2017) Islanded facial artery musculomucosal flap for tongue reconstruction. Int J Oral Maxillofac Surg 46(4):453–455View ArticlePubMedGoogle Scholar
- 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):1084–1087View ArticlePubMedGoogle Scholar