|Year : 2018 | Volume
| Issue : 1 | Page : 16-20
Oral and maxillofacial soft tissue reconstruction using local flaps in Sokoto, Northwest Nigeria
Abdurrazaq Olanrewaju Taiwo1, Ramat Oyebunmi Braimah1, Adebayo Aremu Ibikunle1, Micah Olalekan Gbotolorun2, Mike Adeyemi2, Benedict Chukwuma1, Siddiq Abubakar1
1 Department of Dental and Maxillofacial Surgery, College of Health Sciences, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Nigeria
|Date of Web Publication||14-Mar-2019|
Dr. Ramat Oyebunmi Braimah
Department of Dental and Maxillofacial Surgery, Usmanu Danfodio University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Owing to the aesthetics and functional concern, oral and maxillofacial soft tissue reconstruction requires meticulous planning with team approach. The aim of this paper is to present our experience in the use of local flaps in the reconstruction of oral and maxillofacial defects. This was a retrospective study of maxillofacial and oral soft tissue reconstruction using local flaps.
Patients and Methods: The study was carried out in the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital in northwest Nigeria over a 4-year period. Data such as age, sex, diagnosis, types of flaps used, complications and prognosis were collected and analysed with the IBM SPSS Statistics for windows Version 20 (Armonk, NY: IBM Corp).
Results: Forty-two out of 64 cases of oral and maxillofacial soft tissue reconstruction (65.6%) met the inclusion criteria for local flap utilisation. They consisted of 27 (64.3%) males and 15 (35.7%) females, with a male:female ratio of 1.8:1. Age ranged from 6 to 72 years with mean ± SD (24.2 ± 17.7). Temporomandibular joint ankylosis (TMJA) release was the main reason for soft tissue flap utilisation as an interpositional material in the maxillofacial region 30 (77.3%). Temporalis myofascial flap 19 (45.2%) was the commonest flap used. Most of our cases had no associated complications 39 (92.9%), only 2 (4.8%) patients had total flap failure.
Conclusion: Where free tissue transfer is not feasible, local flaps remain a viable option. Good patient selection is essential to prevent some of the complications associated with their use.
Keywords: Local flaps, maxillofacial, post-surgical defects, reconstruction, resection
|How to cite this article:|
Taiwo AO, Braimah RO, Ibikunle AA, Gbotolorun MO, Adeyemi M, Chukwuma B, Abubakar S. Oral and maxillofacial soft tissue reconstruction using local flaps in Sokoto, Northwest Nigeria. Arch Int Surg 2018;8:16-20
|How to cite this URL:|
Taiwo AO, Braimah RO, Ibikunle AA, Gbotolorun MO, Adeyemi M, Chukwuma B, Abubakar S. Oral and maxillofacial soft tissue reconstruction using local flaps in Sokoto, Northwest Nigeria. Arch Int Surg [serial online] 2018 [cited 2019 Jul 22];8:16-20. Available from: http://www.archintsurg.org/text.asp?2018/8/1/16/254141
| Introduction|| |
Oral and maxillofacial reconstruction is of key importance in the management of defects in the head and neck region caused by trauma, congenital, infective or tumour ablation.,
Following ablative surgery, timely wound closure and the restoration of form, aesthetics and oral function are the primary goals of the reconstruction team., Principles of surgical reconstruction emphasises early return of patients to oral functions such as eating, drinking and good speech leading to improved oral health-related quality of life. There are many reconstructive techniques available to the reconstructive surgeon for the early return of patients to function and to generally improve their quality of life. These techniques include, skin/mucosa grafts (split or full thickness), bone grafts and flaps (local, regional or free tissue transfer). These tissues can come in different composition to suit the defect.
Local flaps are flaps that are located adjacent to the defect site, these flaps tend to be similar in colour and texture, and the thickness can often be tailored to the needs of the defect. These local flaps can be advanced, transposed or rotated into position to reconstruct the defect. Generally, blood supply of local flaps is either via an axial pattern or by a random pattern. Axial pattern local flaps receive their blood supply from a single nutrient vessel while random pattern local flaps receive blood supply by capillary network in a random pattern from all directions.
Few studies have reported the use of local flaps in the reconstruction of oral and maxillofacial defects in Nigeria. Thus, the aim of this paper is to highlight the types of local flaps used for oral and maxillofacial soft tissue reconstruction in the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, northwest Nigeria.
| Patients and Methods|| |
This was a retrospective study of our experience in the use of local flaps for oral and maxillofacial soft tissue reconstruction in the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto northwest Nigeria from 2014–2017. Information retrieved includes age, sex, diagnosis, types of flaps used, complications and prognosis. Inclusion criteria are patients with oral and maxillofacial soft tissue reconstruction using local flaps with complete information, while exclusion criteria are case notes with incomplete or missing records.
Data were stored and analysed using the IBM SPSS Statistics for windows Version 20 (Armonk, NY: IBM Corp). Results were presented as simple frequencies. Statistical significance was set at P < 0.05.
| Results|| |
Forty-two out of 64 cases of oral and maxillofacial soft tissue reconstruction (65.6%) met the inclusion criteria for local flap utilisation. They consisted of 27 (64.3%) males and 15 (35.7%) females, with a male:female ratio of 1.8:1 [Table 1]. Age ranged from 6 to 72 years with mean ± SD (24.2 ± 17.7). Most of the patients were between age group of 11–20 years 13 (30.9%) [Table 1].
Temporomandibular joint ankylosis (TMJA) release was the main reason for soft tissue flap utilisation as an interpositional material in the maxillofacial region using local flaps 30 (77.3%) with a statistical significance of P = 0.000. This was followed by carcinoma in pleomorphic adenoma and rhabdomyosarcoma 3 (7.1%) cases each. Other diagnoses were as shown in [Table 2]. Most of the diagnoses were observed in the age group of 1–20 years.
Temporalis myofascial flap 19 (45.2%) was the commonest flap used in our series, this was closely followed by masseter flap 11 (26.2%). Other flaps used were shown in [Table 2]. Most of our cases had no associated complications 39 (92.9%), while only 2 (4.8%) had total flap failure [Table 3]. Follow-up period ranged from 0 to 12 months with mean ± SD (6.7 ± 2.7). When types of flaps were compared with outcome, most of the patients survived 37 (88.1%), while 2 (4.8%) deaths were recorded [Table 3].
|Table 3: Distribution of types of flaps with associated complications and outcome|
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| Discussion|| |
The maxillofacial region is the main centre of human identity and it also significantly contributes to the individual perception of his/her beauty. In addition, the soft tissues in this region are required for specialised functions such as vision, respiration, mastication, swallowing and speech. When defects of soft tissues occur in this region, these specialised functions are greatly compromised resulting in psychosocial morbidity, general low quality of life and loss of self-esteem.
Reconstruction of maxillofacial region is a technically demanding and time-consuming process because of the specialised functions of the tissues involved. Due to the early return to oral function and aesthetics concern, meticulous planning with team approach is essential. There are many techniques available for oral and maxillofacial soft tissue defects reconstruction depending on the site, size and shape of the defect, past medical history, age and sex of patient, patient's preference, surgeon expertise and available equipments/materials.,,,, These techniques includes skin/mucosa grafts (split or full thickness), bone grafts and flaps (local, regional and distant flaps). Examples of local flaps include: forehead, nasolabial, submental, Karapandzic, temporal myofascial, cervical, platysma and masseter. These flaps are located within the vicinity of defect and can be rotated, transposed or advanced to reconstruct facial defects.
The temporoparietal fascial flap is one of the most all round flaps in the head and neck reconstruction and its use has been described by Monks in the 19th century for the reconstruction of eyelid and auricular defects. The temporalis muscle which is a Type III muscle flap is another versatile option in the head and neck reconstruction. Temporalis myofascial (when both muscle and fascia are taken together) flap was the commonest flap utilised in our series 19 (45.2%). This was so, because the authors have found this flap useful as an interpositional material in preventing TMJ re-ankylosis after surgical release of ankylotic mass. This flap was further anchored to the submandibular region to prevent contraction of the flap and subsequent removal as interpositional material that may lead to re-ankylosis. The temporalis myofacial flap has been commonly used in the reconstruction of maxillectomy defects and to restore dynamic function in facial nerve paralysis. Apart from its utilisation as interpositional material in TMJ ankylosis, the temporalis myofascial flap was also used in two of our patients after excision of rhabdomyosarcoma of the cheek region as an intraoral lining before been covered externally by platysma flap. Its advantages include ease of access to the muscle and ability to transfer the muscle to the oral cavity. Its major drawback which was also encountered in our series is the short length of the muscle necessitating arch of rotation to reach the maxilla.
The masseter muscle has been less utilised for oral reconstructive procedures despite being versatile. Its use has been widely reported for reanimation following facial nerve palsy. The flap can be inferiorly or superiorly based. In our series, the masseter muscle flap was used as interpositional when the TMJA involved the ramus of the mandible. This was because of the close proximity of the masseter muscle to the osteotomy site. The masseter muscle flap has been reported as interpositional material in the prevention of TMJ re-ankylosis. Reduction in mouth opening as a documented complication of this flap was not observed in our patients, possibly because of the post-operative jaw exercise required to prevent TMJ re-ankylosis.
Cervical flap also known as cervicofacial flap/cheek. Mustarde flap when it is used to reconstruct large facial defect is another versatile flap in maxillofacial soft tissue reconstruction. The flap has been described in various forms including a cervicopectoral extension. The blood supply to this fasciocutaneous flap is random pattern because it is elevated just below the subcutaneous layer. When the dissection of the flap is below the musculoaponeurotic layer involving the platysma muscle, then it becomes a myofasciocutaneous flap with axial pattern blood supply. Cervical flap was used in 3 (4.7%) of our patients, however, we did not have the pectoral extension of the flap because only the cervical aspect was adequate for the closure of the defect. In 2 (3.1%) cases we dissected the cervical flap below the musculoaponeurotic layer to involve the platysma muscle (platysma flap) thus making it a myofasciocutaneous flap with axial blood supply. This dissection below the musculoaponeurotic layer has been documented to preserve the perforators and improve perfusion of the flap.
In 2 (3.1%) patients, submental flap was used (one case each of gunshot injury and after dermatofibrosarcoma protuberans excision) [Figure 1]a,[Figure 1]b,[Figure 1]c. The submental island flap was first mentioned in the literature by Martin et al. They described this new flapas a good option to reconstruct various defects in the head and neck region. It is a fasciocutaneous flap based on submental artery which is a direct branch of the facial artery. Advantage of this flap is that the scar is well hidden below the chin; however, the main disadvantage is the difficult dissection of the artery which lies deep into the submandibular gland. In the patient with gunshot injury, the submental flap was combined with a Karapandzic flap to close the defect created [Figure 2]a and [Figure 2]b. The Karapandzic flap has long been used for the reconstruction of larger lip defects. The flap is particularly useful in repairing defects of the lower lip that approach total defect. The main disadvantage of the flap is that it inevitably results in microstomia. This disadvantage was observed in our series as the patient presented with microstomia. Commissuroplasty was planned for this patient as a secondary procedure; however, patient was satisfied with his status and declined further surgery.
|Figure 1: a: Submental flap outline, b: raising of submental flap, c: closure of defect with submental flap|
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|Figure 2: a: Markings for the Karapandzic flap, b: closure of defect with Karapandzic flap|
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One of the oldest flaps used in the reconstruction of facial defects is the paramedian forehead flap. Its use has been dated to 1500BC where it was used to reconstruct nasal defects. Millard revised the flap several years later by thinning the base and rendering the blood supply based solely on the supratrochlear vessels. This modification has increased the reliability of the flap by reducing the torsion on the vessels leading to better perfusion and reduced congestion. The paramedian flap was harvested as a full fasciocutaneous flap for the reconstruction of nasal defect in a road traffic accident victim [Figure 3]a and [Figure 3]b. In another patient, it was harvested as a fascial flap to reconstruct the lower eyelid in post-road traffic accident victim. Fernandes has stated that this flap is not only limited to the nose alone but can also be used to reconstruct defects that falls within its arch of rotation.
|Figure 3: a: Nasal defect with markings for the paramedian frontal flap, b: closure of defect with paramedian flap|
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In all our series, total flap failure was observed in 2 (4.8%) of our patients; 1 (2.4%) case of temporalis myofascial flap and 1 (2.4%) case of cervical flap. In the temporalis myofascial flap patient, we opined that scarifying the superficial temporal artery because of tumour involvement during the primary tumour surgery might have contributed to reduced perfusion of the flap and eventual flap failure. Although, this flap is a Type III flap with blood supply from two arteries, the middle temporal artery which is a branch of superficial temporal artery have been described by Cheung as a major vascular contributor to the temporalis muscle. In the cervical flap patient, the subcutaneous layer and the platysma muscle was greatly compromised by tumour enlargement leading to vascular insufficiency that might have led to its failure.
| Conclusion|| |
Where free tissue transfer is not feasible, local flaps remain a viable option. From our study, local flaps have provided first-rate tissues for oral and maxillofacial soft tissue reconstruction despite several reconstructive techniques available. Good patient selection is essential to prevent some of the complications associated with their use.
The authors are grateful to the health records department during data collection and documentation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
O'Fearraigh P. Review of methods used in the reconstruction and rehabilitation of the maxillofacial region. J Ir Dent Assoc 2010;56:32-7.
Brown JS, Rogers SN, McNally DN, Boyle MA. Modified classification for the maxillectomy defect. Head Neck 2000;22:7-26.
Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 2006;94:538-45.
Mitchell D. An Introduction to Oral and Maxillofacial Surgery. Oxford: Oxford University Press; 2005. p. 380.
Knezevic P, Uglesic V, Jokic D. Quality of life assessment for intraoral reconstruction. Acta Stomat Croat 2002;36:47-50.
Fernandes R. Local and Regional Flaps in Head and Neck Reconstruction: A Practical Approach. 1st
ed. Ames, Iowa 50010, USA: John Wiley and Sons, Inc; 2015.
Chandu A, Bridgeman AM, Smith ACH, Flood SJ. Reconstructive techniques for the repair of oral and maxillofacial oncological procedures: What are they, how do they work and what do they look like? Austr Dent J 2002;47:99-105.
Agbara R, Obiadazie AC, Fomete B, Omeje KU. Orofacial soft tissue reconstruction with locoregional flaps in a health resource-depleted environment: Experiences from Nigeria. Arch Plast Surg 2016;43:265-71.
De Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg 2010;43:200-5.
] [Full text]
Yonehara Y, Nakatsuka T. Reconstruction of oral and maxillofacial soft tissue defects. Japan J Oral Maxillofac Surg 2015;61:496-504.
Harris CM, Laughlin R. Reconstruction of hard and soft tissue maxillofacial defects. Atlas Oral Maxillofac Surg Clin North Am 2013;21:127-38.
Baliarsing AS, Thorat TS, Gupta A. Flap selection in head and neck cancer reconstruction. Int J Otorhinolaryngol Clin 2013;5:63-76.
Cesteleyn L. The temporoparietal galea flap. Oral Maxillofac Surg Clin N Am 2003;15:537-50.
Mathes S, Nahai F. Classification of the vascular anatomy of muscles: Experimental and clinical correlation. Plast Reconstr Surg 1981;67:177-87.
Balaji SM. Modified temporalis anchorage in craniomandibular reankylosis. Int J Oral Maxillofac Surg 2003;32:480-5.
Edwards SP, Feinberg SE. The temporalis muscle flap in contemporary oral and maxillofacial surgery. Oral Maxillofacial Surg Clin N Am 2003;15:513-35.
Mahieu R, Russo S, Gualtieri T, Colletti G, Deganello A. Oral cavity reconstruction with the masseter flap. Acta Otorhinolaryngol Ital 2016;36:139-43.
Braimah RO, Oladejo T, Olarinoye TO, Adetoye AO, Osho PO. A multidisciplinary approach to the management of TMJ ankylosis in a sickle-cell anaemia patient in a resource-limited setting. Ann Maxillofac Surg 2016;6:130-4.
] [Full text]
Antoniades K, Lasaridis N, Vahtsevanos K, Hadjipetrou L, Antoniades V, Karakasis D. Superiorly based and island masseter muscle flaps for repairing oropharyngeal defects. J Craniomaxillofac Surg 2005;33:334-9.
Garrett WS, Giblin TR, Hoffman GW. Closure of skin defects of the face and neck by rotation and advancement of cervicopectoral flaps. Plast Reconstr Surg 1966;38:342-6.
Martin D, Pascal JF, Baudet J, Mondie JM, Farhat JB, Athoum A, et al
. The submental island flap: A new donor site. Anatomy and clinical applications as a free or pedicled flap. Plast Reconstr Surg 1993;92:867-73.
Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93-7.
Alford EL, Baker SR, Shumrick KA. Midforehead flap. In: Baker SR, Swanson NA, editors. Local Flaps in Facial Reconstruction. St. Louis: MO: Mosby; 1995. p. 197-223.
Millard DR. Total reconstructive rhinoplasty and a missing link. Plast Reconstr Surg 1996;37:167-83.
Cheung LK. The vascular anatomy of the human temporalis muscle: Implications for surgical splitting techniques. Int J Oral Maxillofac Surg 1996;25:414-21.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]