Download Total soft palate reconstruction using the palatal island and lateral

The Laryngoscope
C 2012 The American Laryngological,
V
Rhinological and Otological Society, Inc.
How I Do It
Total Soft Palate Reconstruction Using the Palatal Island
and Lateral Pharyngeal Wall Flaps
William E. Karle, BS; Sumeet M. Anand, MD, MSc; Jason B. Clain, BS;
Sophie Scherl, BA; Mark L. Urken, MD, FACS
Key Words: Reconstructive surgical procedures, palatal island flap, soft palate reconstruction, lateral
pharyngeal wall flap.
Laryngoscope, 123:929–933, 2013
INTRODUCTION
MATERIALS AND METHODS
The palatal island flap has been well described for
head and neck cancer reconstruction to repair defects
in sites such as the soft palate, hard palate, retromolar
trigone, cheek, tonsil, and lateral pharyngeal wall.1–6
This flap is particularly versatile; however, when used
alone for soft palate repair the technique provides only
an adynamic reconstruction. In view of this, the lateral
pharyngeal wall flap can be used in conjunction with
the palatal island to add a dynamic feature that can
help to restore the sphincteric function of the
velopharynx.
We report the use and advantages of employing
the palatal island flap in conjunction with the lateral
pharyngeal wall flap in a single-staged reconstruction
of large soft palate defects. This operation has been
highly successful, with low complication rates, due to
the high vascularity of the involved flaps, decrease in
surgical complexity, and recreation of mucosal lining to
the oral and nasal surfaces of the repair. The latter feature helps to add to the predictability of the results
through the prevention of granulation tissue formation.
We propose that this procedure be considered more
often in the surgical reconstruction of large soft palate
defects.
In select cases, an elective tracheostomy should be considered at the beginning of the operation for airway protection.
Once the resection of the soft palate is performed, an oncologic
clearance of the tumor is established by frozen section analysis
prior to embarking on the reconstruction (Fig 1). Subsequently,
restoring the velopharynx can be undertaken. The nasopharyngeal surface of the soft palate is created with two opposing
musculomucosal flaps from the lateral pharyngeal wall. The lateral pharyngeal walls are undermined in a submuscular plane
starting at the posterior margin of the resection, usually at the
level of the posterior tonsillar pillar (Fig. 2). The myomucosal
superior and medial pharyngeal constrictors and pharyngeal
mucosa are recruited from the lateral pharynx and advanced to
the midline to form the nasopharyngeal surface of the neo-soft
palate. Creation and closure of the inner myomucosal tube on
itself creates a single dynamic chamber from the nasopharynx
to the oropharynx (Fig. 3). Once the nasopharyngeal aspect of
the soft palate has been created, attention is directed to the
palatal island flap.
Harvest of the palatal island is initiated by making an incision around the perimeter of the hard palate mucosa within a
5-mm gingival margin medial to the teeth. The incision is
extended posteriorly to the hard and soft palate junction bilaterally. Using a freer elevator, the mucoperiosteum is elevated from
the bone in an anterior to posterior fashion. One neurovascular
pedicle is preserved, whereas the other is ligated with surgical
clips. The flap is rotated 180 on its axis, maintaining the mucosal surface oriented toward the oral cavity. The entire palatal
island flap is subsequently sutured directly to the margins of
the defect with its deep surface apposing the transposed myomucosal pharyngeal flaps to form the oropharyngeal surface of the
neo-soft palate. The suture line usually extends laterally along
the anterior tonsillar pillar and helps to ensure the posterior
positioning of the palatal island flap. The transposed palatal
island flap has a tendency to lift away from the palatal bone
along its leading edge. This can be overcome by placing boneanchored sutures that are drilled into the palatal bone along the
edge and used to appose the palatal flap to the boney surface
(Fig. 4). Tension-free closure is imperative on the nasopharyngeal and oropharyngeal side of the neo-soft palate (Fig. 5).
From the Albert Einstein College of Medicine (W.E.K.); Thyroid Head
and Neck Cancer Foundation (W.E.K., J.B.C., S.S.); and Department of
Otolaryngology–Head and Neck Surgery (S.M.A., M.L.U.), Beth Israel
Medical Center, New York, New York, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
September 19, 2012.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to William E. Karle, 9 Ryan Rd., Troy, NY
12182. E-mail: [email protected]
DOI: 10.1002/lary.23787
Laryngoscope 123: April 2013
Karle et al.: Soft Palate Reconstruction
929
Fig. 1. Palatal tumor. Preoperative appearance of a carcinoma
involving the central soft palate with the proposed lines of
resection.
Fig. 3. Nasopharyngeal surface of neo-soft palate. The myomucosal constrictor flaps are advanced and sutured together in the
midline to resurface the nasopharyngeal surface of the neo-soft
palate. This restores the dynamic sphincteric function of the velopharynx and achieves a mucosal-lined conduit as well.
RESULTS
We report the representative case of a 74-year-old
female with a 70 pack-year smoking history who originally presented with odynophagia and was diagnosed
with squamous cell carcinoma of the central portion of
the soft palate (Fig. 6). Because the tumor crossed the
midline, the patient underwent a total soft palatectomy
and bilateral cervical lymph node dissections. Pathological
analysis demonstrated a 4-cm, moderately differentiated,
squamous cell carcinoma with invasion into underlying
skeletal muscle. All resection margins were negative.
This defect was reconstructed using two lateral
pharyngeal wall flaps in conjunction with a palatal
island flap in the manner described above. The postoperative course was unremarkable and she was started on a
liquid oral diet 7 days postoperatively and discharged on
day 10. At her 4-week follow-up visit, the wound was
well healed and she did not complain of any discomfort.
The anterior palatal bone had remucosalized at this
point in time. At this point the patient was not experiencing any difficulties with nasal breathing. Video nasal
endoscopy, nasometry, and modified barium swallow
examinations showed velopharyngeal closure upon deglutition and an absence of hypernasality and
regurgitation (Figs. 7–9). When this article was submitted, the patient was 12 months postoperative with no
documented recurrence and was eating a regular diet. It
is important to mention that this patient did not receive
radiation therapy postoperatively. This decision was
made due to the lack of evidence of suspicious adenopathy on preoperative imaging and because the patient
was pathologically N0 following bilateral selective neck
dissections.
DISCUSSION
Fig. 2. Raising lateral pharyngeal wall flaps. Following resection of
the entire soft palate, the lateral walls of the oropharynx, with the
underlying constrictor muscles, are recruited by undermining in
the prevertebral plane and advancing those flaps to the midline.
Laryngoscope 123: April 2013
930
Today, there are several different procedures available to surgeons for the reconstruction of large soft palate
defects. These include, but are not limited to, the use of
various tongue, buccal, pharyngeal, palatal, and free flaps
as well as the use of prosthetic obturators.2,3,6–9 Faced
with this wide variety of options it is important to know
what realistic outcomes one can expect and how reliably
one can achieve them. The goals for soft palate reconstruction include preserving swallow function and
maintaining normal speech, while also minimizing donor
Karle et al.: Soft Palate Reconstruction
Fig. 4. Transposition of palatal
island. The palatal island flap is harvested and transposed through an
arc of 180 to resurface the oral side
of the neo-soft palate. The palatal
island flap is sutured to the edges of
the defect as shown, including the
free edge of the myomucosal flaps
that are lining the nasopharynx. The
anterior edge of the palatal island
flap is anchored to the bone with
the use of bone-anchored screws
and attached sutures that achieve
adherence of that edge to the palatal bone.
site morbidity.7,10,11 One of the pitfalls associated with
several reconstructive techniques is the adynamic nature
of the newly created soft palate. Although free tissue
transfer has become a common practice in head and neck
reconstruction, this creates a repair that produces a relatively immobile soft palate. It is a direct result of its
adynamic nature that may this approach may cause complications in speech and swallowing function.
Although the palatal island flap acts as an adynamic
replacement for the soft palate,12 the lateral pharyngeal
Fig. 5. Finalized creation of the neo-soft palate. The reconstructed
soft palate achieves the goal of a mucosal-lined and dynamic
conduit between the oropharynx and the nasopharynx. The hard
palate remucosalizes over the course of several weeks through
the process of healing by secondary intention.
Laryngoscope 123: April 2013
wall maintains its muscular innervation allowing contraction with each swallow, facilitating sphincter closure. The
recruitment of constrictor muscles allows closure of a velopharynx, which although smaller in caliber than the
native pharyngeal opening, remains dynamic. Of note,
suturing the palatal island flap to the transposed lateral
pharyngeal wall flaps prevents the anterior migration of
the free edge of the neo-soft palate, which occurs in most
forms of soft palate reconstruction. Closure of the velopharyngeal sphincter through apposition of the soft palate
and superior pharyngeal constrictor muscles separates
the nasopharynx from the oropharynx, which is essential
for normal deglutition and speech. Previous studies have
shown that when used in conjunction with an adynamic
flap, the pharyngeal wall flap can also greatly decrease
the incidence of nasality.12 Zeitels and Kim13 have also
noted success obtaining velopharyngeal competence with
a similar superior-constrictor advancement-rotation flap.
Fig. 6. Carcinoma prior to resection. Intraoperative planning for
soft palate resection marked with purple dye. Carcinoma visualized at 3 cm in diameter at the posterior margin of the soft palate.
Karle et al.: Soft Palate Reconstruction
931
Fig. 7. Postoperative sagittal computed tomography (CT). Sagittal
CT view of the patient 1 month postoperatively. Arrow points to
the neo-soft palate.
In our experience, none of our patients undergoing the
procedure described have required speech therapy for
hypernasality.
In our current era of functional reconstruction, a
basic premise is to use the simplest and safest technique
to accomplish a desired goal. As such, the benefit of
using local flaps to ideally restore defects using ‘‘like tissue’’ represents the ideal method in most circumstances,
provided it achieves the desired goals and does not disturb the functionality of the region from which the
tissue is transferred.3 Although free tissue can be transferred to the head and neck using microvascular
techniques, the oral cavity and oropharynx remain ideal
donor sites to restore the soft palate without incurring
significant secondary morbidity.
Although the lateral pharyngeal wall flap has been
used in combination with other adynamic flaps for soft
palate reconstruction, the palatal island offers the simplest and most resilient option. The palatal island flap is
an ideal treatment for oropharyngeal defects because of
its thin, pliable, highly vascularized, sensate, and
mucous-secreting properties.4 Taking periosteum with
the palatal island flap also gives rigidity to the neo-soft
palate. Another advantage of employing this flap over
others is that the secondary defect overlying bone is able
to heal by secondary intention within 4 to 6 weeks, provided that the patient has not been previously treated
with radiation therapy, which is a contraindication to the
use of this flap. Because healing by secondary intention
often leads to contraction of the donor site defect, the use
of the palatal island flap is unique in that the remucosalization of the hard palate is not at risk for distortion due
to the fact that it is occurring over a boney surface.10
Usually this technique is a great surgical option; however, it has certain contraindications including previous
radiation therapy to the palate, ipsilateral external carotid
or internal maxillary artery ligation, or previous oral or
Laryngoscope 123: April 2013
932
Fig. 8. One month postoperative nasoendoscopy. (a) Patent velopharynx at rest. (b) Complete closure of the velopharynx while the
patient is instructed to say ‘‘papapa.’’
oropharyngeal surgery that has significantly disturbed the
vascular supply.3,4 In addition, the use of this procedure is
not recommended for smaller soft palate defects, where
simpler reconstructive options are preferable.
Fig. 9. Three months postoperative neo-soft palate. Complete
healing of the donor and recipient sites within the oropharynx.
Karle et al.: Soft Palate Reconstruction
CONCLUSION
The benefits achieved by combining these two pedicle
flaps are: 1) maintaining dynamic function of the soft palate, 2) maintaining function of the superior and middle
posterior wall constrictors, 3) preventing nasality in speech
and nasal regurgitation, 4) lowering risks of patient and
donor site morbidity, and 5) creating a simplified surgical
procedure as compared to microvascular free tissue transfer. Although advancements in microsurgery have driven
the expansion in the use of free tissue transfer, this article
demonstrates the continued importance and advantages of
using local pedicle flaps in soft palate reconstruction.
BIBLIOGRAPHY
1. Seckel NG. The palatal island flap on retrospection. Plast Reconstr Surg
1995;96:1262–1270.
2. Gullane PJ, Arena S. Palatal island flap for reconstruction of oral defects.
Arch Otolaryngol Head Neck Surg 1977;103:598–599.
3. Genden EM, Lee BB, Urken ML. The palatal island flap for reconstruction
of palatal and retromolar trigone defects revisited. Arch Otolaryngol
Head Neck Surg 2001;127:837–841.
Laryngoscope 123: April 2013
4. Gullane PJ, Arena S. Extended palatal island mucoperiosteal flap. Arch
Otolaryngol Head Neck Surg 1985;111:330–332.
5. James R. Surgical closure of large oroantral fistulas using a palatal island
flap. J Oral Surg 1980;38:591–595.
6. Ducic Y, Herford AS. The use of palatal island flaps as an adjunct to microvascular free tissue transfer for reconstruction of complex oromandibular defects. Laryngoscope 2001;111:1666–1669.
7. Kimata Y, Uchiyama K, Sakuraba M, et al. Velopharyngeal function after
microsurgical reconstruction of lateral and superior oropharyngeal
defects. Laryngoscope 2002;112:1037–1042.
8. Komisar A, Lawson W. A compendium of intraoral flaps. Head Neck Surg
1985;8:91–99.
9. Chepeha DB, Sacco AG, Erickson VR, et al. Oropharyngoplasty with template-based reconstruction of oropharynx defects. Arch Otolaryngol
Head Neck Surg 2009;135:887–894.
10. Harrid JR, Seikaly H, Urken ML, Okay DJ, Rieger J. Oropharyngeal
reconstruction. In: Urken ML, ed. Multidisciplinary Head and Neck
Reconstruction: A Defect-Oriented Approach. Philadelphia, PA: Lippincott Williams &Wilkins; 2010:647–688.
11. Moore BA, Magdy E, Netterville JL, Burkey BB. Palatal reconstruction
with the palatal island flap. Laryngoscope 2003;113:946–951.
12. Brown JS, Zuydam AC, Jones DC, Rogers SN, David Vaughan E. Functional outcome in soft palate reconstruction using a radial forearm free
flap in conjunction with a superiorly based pharyngeal flap. Head Neck
1997;19:524–534.
13. Zeitels SM, Kim J. Soft-palate reconstruction with a ‘‘SCARF’’ superiorconstrictor
advancement-rotation
flap.
Laryngoscope
1998;108:
1136–1140.
Karle et al.: Soft Palate Reconstruction
933