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Indian Journal of Plastic Surgery, Vol. 36, No. 2, Dec, 2003, pp. 120-122 Case Report Reconstruction of complete palatal defect with a forehead flap: A case report Sadhotra LP, Singh M, Raje R Plastic and Reconstructive Surgery, Armed Forces Medical College, Pune - 411040 Code Number: pl03026 ABSTRACT Panfacial injuries may require composite reconstruction of the palate, or the use of an obturator. Composite reconstruction can be by a pedicle flap, which may be local, regional or micro vascular free tissue transfer. We report reconstruction of a complete defect of the palate using a forehead flap in a 34-year-old male patient.INTRODUCTION Panfacial injuries when accompanied by loss of palate pose problems such as nasal regurgitation, hypernasality of speech, and inability to masticate. The options are either a composite reconstruction of the palate, or the use of an obturator. Composite reconstruction can be by a pedicle flap, which may be local, regional or micro vascular free tissue transfer. We have reconstructed a complete defect of the palate using a forehead flap. CASE REPORT A 34-year-old male patient suffered panfacial fractures following a road traffic accident on 16 Nov 1996. After initial resucitation, the patient was transferred to this center where internal fixation was done for Le Forte III and mandibular fractures and the right eye was eviscerated. Later he underwent stabilization of the floating maxilla by an onlay bone graft. Subsequently the patient presented with hyper nasality of speech and nasal regurgitation. He had a dish face deformity, bilateral anti-mongoloid slant and complete palatal loss, with only a few teeth in the posterior segment [Figure - 1]. The palate was reconstructed using a forehead flap based on the right side. The entire aesthetic unit of the forehead was elevated based on the anterior division of the superficial temporal artery. The flap was lined with a split skin graft, tunneled through the cheek so that the skin graft was on the nasal side and then sutured into the defect [Figure - 2]. The donor site was covered with a split skin graft. Patient was fed liquid diet through an intra-gastric tube. No interdental fixation was used postoperatively. The flap had a marginal inset only but there were no problems in the vascularity. The flap was delayed after 3 weeks and then divided and inset after another week. Postoperative period was uneventful and the patient recovered significantly from nasal regurgitation. There was an appreciable improvement in hypernasality. When reviewed after 3 months, the flap had settled very well. There was no fistula and the patient was happy with his result [Figure - 3] DISCUSSION Communication between the oral and nasal cavities is often a cause of significant morbidity. The speech in such patients is incomprehensible as there is hyper nasality and absence of palate. There is inability to masticate because of nasal regurgitation of food.[1],[2] Mastication is further compromised if there is loss of teeth. The options for reconstruction are either an obturator between the oral and nasal cavities[6],[7] or the use of composite tissue in the form of a flap.[3],[4],[5],[6],[7] Flap cover for complete palatal defect can be given by regional or distant flaps. A regional flap is raised from a tissue in the same anatomical region as the defect, such as tongue, bilateral temporalis[3],[6],[8] or the forehead flap. A distant flap is taken from any other anatomical site in the body, such as a micro vascular free tissue transfer.[4],[5] An obturator is the easiest option for reconstruction where adequate number of teeth ensure good fitting. However it has disadvantages of causing discomfort, foul taste, odour and nasal regurgitation when the fit is imperfect.[1],[2],[8] A tongue flap is readily available in the vicinity,[6],[7] but is a morbid procedure and the flap will not suffice to meet the requirement for total palatal loss. Bilateral temporalis muscle flaps are very reliable, since they have a good vascularity, but have a disadvantage of being bulky and will sag into the oral cavity, causing obstruction[1],[2]. Micro-vascular transfer of iliac bone with jejunum addresses the problem of covering the palatal defect and replacing the loss of teeth since osseo-integrated implants can be applied on the transferred bone. In this procedure a laprotomy is required and there is a relatively high risk of flap loss. Forehead flap has the advantage of being locally available. In addition, the flap is thin and has a long reach. In our experience, the flap did not sag into the oral cavity [Figure - 2]. The split skin graft on the donor site settled well with an acceptable aesthetic result [Figure - 3]. Reasons for the skin graft facing the nasal side were: - (a) monitoring the distal edge of the flap would be technically easier with the forehead skin facing the oral aspect, (b) the natural lie of the flap was better with the skin graft facing the nasal side. The distal and anterior margins of the flap were completely inset. The posterior margin however was inset partially. Considering the rich vascularity in this area flap neo-vascularisation was not a problem at any stage. Symptomatic relief was adequate and the forehead flap can be another option for total palatal reconstruction. REFERENCES
Copyright 2003 - Indian Journal of Plastic Surgery The following images related to this document are available:Photo images[pl03026f3.jpg] [pl03026f1.jpg] [pl03026f2.jpg] |
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