Clinical
Paper
Reconstructive
Surgery
Soft
palate
functional
reconstruction
with
buccinator
myomucosal
island
flaps
O.Massarelli,L.A.Vaira,R.Gobbi,A.Biglio,G.Dell’aversanaOrabona,G.DeRiu:
Softpalatefunctionalreconstructionwithbuccinatormyomucosalislandflaps.Int.J.
OralMaxillofac.Surg.2018;47:316–323.ã2017InternationalAssociationofOral
andMaxillofacialSurgeons.PublishedbyElsevierLtd. Allrights reserved.
O.Massarelli1,a,L.A.Vaira1,a, R.Gobbi1,A.Biglio1,
G.Dell’aversanaOrabona2, G.DeRiu1
1MaxillofacialSurgeryUnit,University
HospitalofSassari,Sassari,Italy;
2MaxillofacialSurgeryUnit,University
HospitalofNaples‘‘FedericoII’’,Naples,Italy
Abstract. Oropharyngealreconstruction afterablativesurgeryisachallenge.The
resultsofaretrospectivestudyof17patientswhounderwenttotalorsub-totalsoft
palatereconstructionwithabuccinatormyomucosalislandflap,between2008and
2016,arereportedherein.Ananalysisofflaptypeandsize,harvestingtime,and
postoperativecomplicationswasperformed.Patientsunderwentstandardizedtests
toassesstherecoveryofsensitivity,deglutition,qualityoflife(QoL),anddonorsite
morbidity,at>6monthsaftersurgeryortheendofadjuvanttherapy,ifperformed.
Allflapsweretransposedsuccessfully.Only minordonorandrecipientsite
complicationsoccurred.Thesensitivityassessmentshowedthattouch,two-point
discrimination,andpainsensationswererecoveredinallpatients.Significant
differencesbetween theflapandnativemucosawerereportedfortactile
(P=0.004),pain(P=0.001),andtwo-pointdiscrimination(P=0.001)thresholds.
Theaveragedeglutitionscorereportedwas6.1/7,withonlyminimalcomplaints
regardingdeglutition.TheQoLassessmentshowedhighphysical(24.6/28),social
(25/28),emotional(19.1/24),andfunctional(24.6/28)scores.Nomajordonorsite
complicationswerenotedinanypatient;theaveragedonorsitemorbidityscorewas
8.1/9. Buccinatormyomucosalislandflapsrepresentavaluable functional
oropharyngealoptionforreconstruction,requiringashort operatingtimeand
presentinga lowdonorsitemorbidityrate.
Keywords:oropharyngealreconstruction;soft palatereconstruction;buccinatormyomucosal flap; cheek myomucosal flap; FAMM; t-FAM-MIF;BAMMIF;facialarterymyomucosalisland flap;buccalarterymyomucosalislandflap. Acceptedforpublication23November2017 Availableonline8December2017
Thegoalsofheadandneckcancer treat-mentare cure,organpreservation, resto-ration offormandfunction,reductionof themorbidityassociatedwiththerapy,and improvementormaintenanceofqualityof life(QoL)1.
Thefunctionalrestorationoflargesoft palatedefectsposesareconstructive
chal-lenge,duetothecomplexvelopharyngeal anatomy and physiology. This organ is responsibleforproperspeecharticulation andresonance,andisintimately associat-ed withcomplexfunctionssuchas swal-lowingandrespiration.Dysfunctionofthe soft palate followingablative surgery or trauma,leadstotheimpairmentofspeech
andswallowing,whichhaveadevastating impactonthepatient’sQoL2. Reconstruc-tionofthesoftpalateiscomplexbecause thedynamicfibromuscularstructure can-notbeduplicatedwithcurrentcapabilities,
a
Olindo Massarelli and Luigi Angelo Vairaareco-firstauthors.
whichfocus ontherestorationofproper integrity,bulk,andsensation.
Severalreconstructivetechniqueshave been proposed, includingthe use ofsoft palateobturators3andlocal4–6,regional7–
9
,anddistalfreeflaps10–12.Radialforearm freeflapsarecurrentlythefirstchoicefor softpalatereconstruction,allowinga sat-isfactoryfunctionalrehabilitation13–15.
However, the ideal reconstruction should be accomplished with the same or similar type of tissue as the original one.Buccinatormyomucosalislandflaps comprisewell-vascularized,thin,sensate, pliable,andmobiletissuewiththe poten-tialfordynamicfunction,andthusallowa ‘likewithlike’defectrestoration16–21.
Thisstudywasperformedtoinvestigate andreportthefunctionaloutcomesof17 patientswhounderwenttherestorationof totalorsub-totalsoftpalatedefects with buccinatormyomucosalislandflaps. Materialsandmethods
A retrospectivestudywas conducted in-volvingpatientswithsoftpalate post-ab-lative defects, who underwent reconstructive surgery with buccinator myomucosalislandflapsbetweenJanuary 2008andJune2016intheMaxillofacial SurgeryUnitoftheUniversityHospitalof Sassari.Flapharvestingwasperformedas described in previous reports16–21. All patients underwent standardized tests to assesstherecoveryofsensitivity, degluti-tion,QoL,anddonorsitemorbidity,at>6 monthsafter surgery ortheendof adju-vanttherapy,if performed.
Therecoveryofsensitivitywastestedin aquietroomusingdifferentsensorytasks todeterminethepresenceoftactile sensi-tivityanditspressurethreshold,staticand dynamic two-point discrimination, pain sensitivity, sharp/blunt discrimination, andtemperature sensitivity.Thesubjects wereblindfoldedduringalltasks.All sen-sory tests were conducted both on the reconstructiveflapandontheintact oppo-site side to the defect. For patients who presenteddefectsinvolvingthewholesoft palate,theresultscouldobviouslynotbe comparedwithahealthyside.
Tactilesensitivitywasevaluatedusing eight shortened Semmes–Weinstein monofilaments (Premier Products, Kent, WA,USA).Thesewereusedinsequence, from 0.0354g/mm2 to 732.8g/mm2, to determine the tactile threshold. Each monofilament was applied perpendicular to the surface examined, applying suffi-cientpressuretomakethenylonwirebend inaCshapeforapproximately1.5s22,23. Staticanddynamictwo-point
discrimina-tionwereinvestigatedusingsterilized of-ficestaplespre-shapedtoathresholdrange of1–30mmandheldwithaMayo needle-holder20.Thestaple,startingwiththe low-estwidth,waspressedlightlyonthe sur-facebeingexaminedandthepatientwas askediftheyhadfeltoneortwostimuli. Wider stapleswerethen usedin succes-sion until the patient could discriminate the two points. Temperature sensitivity was tested withthree cottonswabs:one wasimmersedinwarmwater(70C),one wascooledwithicespray(3C),andone was leftat roomtemperature.Thesmall cottonballswerethenappliedtothe sur-faceinrandomorder.Thepresenceofpain sensitivitywas assessedwithapricktest using micro-tissue forceps to pinch the surface, and the patients were asked whethertheyfeltpain.Thepainthreshold was determinedwithSemmes–Weinstein monofilaments starting from the tactile thresholddata.Thestimuluswas applied inthesamewayasforthislattertest,but the patient was instructed to open their eyesandraisetheirhandassoonasthey feltnotonlypressurebutalsopaininthe testarea.Iftheparticipanthadnopositive response for the thickest monofilament (732.8g/mm2), this value was recorded asthethreshold22.Sharp/smooth discrim-ination was assessed usinga cotton bud andadentalprobe.Thesetoolswere ap-pliedmultipletimesontothesurfaces,in random order,and thepatientwas asked whethertheycoulddistinguishasharpora smoothobject.
Deglutition was evaluated objectively byplacing differenttypesoffoodinthe patient’s mouth and testing whetherthe subjectcouldspontaneouslyswallowand clear the palate; this method has been described previously by Teichgraeber et al.24. The score could range from 1 (severecomplaintsandunabletoswallow) to7(nocomplaints).
QoLwasassessedusingtheFunctional Assessment of Cancer Therapy – Head andNeckquestionnaire25.Donorsite mor-bidity was evaluated using five parame-ters: mouth opening, oral commissure symmetry, inner vestibule restoration, cheek mucosal lining, and the aesthetic result26.Thisclinicalevaluationwas per-formed by ablinded panelof two clini-ciansandthepatientthemselves,assessing eachparameterwithascorerangingfrom 0to3.Thethreescoresforeachparameter weresummedtoobtainascorereflecting theoverallparameterassessment.
Data collected were analysed using IBM SPSSStatistics version24.0 (IBM Corp., Armonk, NY, USA). Descriptive statisticsforquantitativevariablesare
giv-enasthemeanstandarddeviation(SD). The statistical analysisof differences in thesensitivitythresholdbetweentheflap andthenativemucosawasperformedwith theWilcoxonsigned-ranktest.Thelevel of statistical significance was set at P0.05witha95%confidenceinterval. Thestudywas approvedbytheEthics Committee of the University of Sassari and was conducted in accordance with the Declaration of Helsinki of 1973 as revisedin1983.
Results
Twenty-threepatientsunderwentsoft pal-atereconstructionwithabuccinator myo-mucosal flap between January 2008 and June2016.Oneofthesepatientsdiedfrom pulmonaryrecurrenceandfivepatientsdid notshowupforthestudy.Thesepatients were excluded from the evaluation. The remaining17patientswererecruited. De-mographic data, tumour pathology, the typeand sizeofreconstructiveflap, har-vestingtimes,postoperativerecipientand donorsitecomplications,useofadjuvant radiotherapy,andfollow-updurationsare reportedinTable1.
ThetumourwasclassifiedasT1inone patient, T2ineightpatients,T3inseven patients, and T4 inone patient. Tumour resection was combined with bilateral lymph nodeneckdissectionaccordingto thecriteriaforradicalsurgicaltreatment. In 12 patients with disease classified as cN0, the facial vessels were preserved duringneckdissection,sothebuccinator myomucosalislandflapwasbasedonthe facialartery.Inonecase,apatient classi-fiedascN0wasre-classifiedaspN2bafter histologicalevaluation(Table1;case16). In two cases staged as cN2b (Table 1; cases3and8),thebuccinatormyomucosal islandflapwasbasedonthecontralateral facialartery,takingadvantageofitsuseful pediclelength(Fig.1).Abuccinator myo-mucosal island flap basedon thebuccal artery was used in two cases staged as cN2c(Table1;cases10and15)andinone case inwhichthefacialartery had acci-dentallybeenresectedandligated(Table 1;case1)(Fig.2).Themeanflap harvest-ingtimewas47.6min.
No major complications or flap loss were detectedinthisseries.Minor com-plicationsoccurredintwocases:onecase ofvenous stasis, whichresolved sponta-neously, and one case of minor suture dehiscence. Local or distant recurrence wasnotreportedforanypatient.
Thesensitivityassessmentshowedthat touch,two-pointdiscrimination,andpain sensationswererecoveredinallpatients.
Massarelli
et
al.
Table 1. Patient characteristics. Patient No.
Sex/age at surgery
Diagnosis Tumour size
(according to UICC) Site of defect Type of flap
Flap size (cm) Flap side Flap harvesting time (min) Recipient site complications Donor site complications Adj. RT Follow-up (months) 1 F/58 years SCC pT2N0M0
Left retromolar trigone + hemipharynx + soft hemipalate
BAMMIF 6 4
Left
45 None None None 95
2
M/76 years
SCC pT1N0M0
Uvula + left soft hemipalate t-FAMMIF 4 3 Left
45 None None None 82
3 F/54 years
SCC pT4N2bM0
Left soft hemipalate + maxillary tuberosity + retromolar trigone + left pharynx
t-FAMMIF 7 5
Contralateral
50 None None Yes 69
4 M/67 years SCC pT2N0M0 Uvula t-FAMMIF 6 3 Right
60 None None None 68
5
M/50 years
SCC pT2N0M0
Right soft hemipalate + retromolar trigone
t-FAMMIF 6 5
Right
40 None None None 68
6
M/59 years
SCC pT3N0M0
Total soft palate t-FAMMIF 7 5
Right
60 None None None 59
7
M/61 years
SCC pT3N0M0
Left soft hemipalate + hard palate t-FAMMIF 5 3 Left
45 None None Yes 48
8
M/56 years
SCC pT3N2bM0
Right 2/3 hard palate + soft palate t-FAMMIF 6 4 Contralateral
75 Venous stasis None Yes 40
9
M/63 years
SCC pT2N0M0
Right soft hemipalate t-FAMMIF 6 5
Right
45 None None None 39
10 M/64 years
SCC pT2N2cM0
Left soft hemipalate BAMMIF 5 4
Left
40 None None Yes 34
11 F/58 years
SCC pT2N0M0
Right soft hemipalate t-FAMMIF 7 5
Right
45 None None None 33
12 M/72 years
SCC pT3N0M0
Right soft hemipalate + hard palate t-FAMMIF 7 6 Right
40 None None None 28
13 M/72 years
SCC pT3N0M0
Total soft palate t-FAMMIF 6 5
Left
45 None None None 25
14 F/75 years
SCC pT2N0M0
Left soft hemipalate t-FAMMIF 6 5
Left
45 None None None 19
15 M/54 years
SCC pT2N2cM0
Right soft hemipalate BAMMIF 6 5
Right
40 None None Yes 17
16 M/62 years
SCC pT3N2bM0
Right soft hemipalate + retromolar trigone
t-FAMMIF 6 5
Right
50 None None Yes 12
17 F/70 years
SCC pT3N0M0
Left soft hemipalate t-FAMMIF 6 5
Left
40 Minor suture
dehiscence
None None 8
Adj. RT, adjuvant radiotherapy; BAMMIF, buccal artery myomucosal island flap; F, Female; M, Male; SCC, squamous cell carcinoma; t-FAMMIF, tunnelized facial artery myomucosal island flap; UICC, Union for International Cancer Control.
Significant differences between the flap andnativemucosawerereportedfor tac-tile (P=0.004), pain (P=0.001), and two-point discrimination (P=0.001) thresholds. Three patients were notable to discriminatebetween sharp and blunt stimuli, whiletwopatient didnotreport thermalsensitivity(Table2).Mostofthe patients presented minimal deglutition complaintsandwereabletoswallowthe boluswithoutanydifficulty.Theaverage deglutitionscorereportedwas6.1(Table 3). The QoL assessment showed high physical,social,emotional,andfunctional
well-being (Table 4). In all cases, the donorsitewasrepaired withabuccalfat padharvestedfromthecheek.Donorsite morbiditywasverylow;theaveragedonor sitemorbidityscorewas8.1(Table5). Discussion
Alterationstothecomplexanatomyofthe soft palate,such asthose resulting from resectivesurgery,easilyleadto velophar-yngeal insufficiency, which negatively impacts speech, swallowing, and patient QoL. Soft palate reconstruction has two
primary goalstodealwiththisproblem: (1)closureoftheoronasalcommunication withadequatetissuequantity,(2) re-crea-tion ofa functional myomucosalvelum, whichneedsasensate,pliable,andmobile tissuewiththepotentialfordynamic func-tion4.
Palatal obturators have been used to close soft palate defects, but their lack of mobility along with the surrounding muscularpharyngealtube,resultsin inef-fectivesealingduringdynamicmotionin speechandswallowing.Moreover, eden-tulouspatientsoftenexperiencedifficulty
Softpalatefunctionalreconstruction
Fig.1. Case3,a54-year-oldfemalepatient.(A)Post-ablativedefectinvolvingthelefthemipalateandipsilateralmaxillarytuberosity,lateral pharyngealwall,retromolartrigone,andbaseofthetongue.(B)Atunnelizedfacialarterymyomucosalislandflap(t-FAMMIF)washarvested fromthecontralateralcheek.(C)Theflapwaspulledbackintotheoralcavityandsuturedattherecipientsite.(D)Follow-upat26months.
Fig.2. Case10,a64-year-oldmalepatient.(A)Lefthemipalatedefectfollowingtumourablation.(B)Buccalarterymyomucosalislandflap (BAMMIF)harvestedfromtheleftcheek.(C)Theflapwastransposedandsuturedattherecipientsite;thedonorsitewasclosedwithapedicled buccalfatpadflap.(D)Follow-upat11months.
Massarelli
et
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Table 2. Results of sensitivity tests after 6 months of follow-up. Patient No.
Sex/age (years) Soft touch Tactile threshold (g/mm 2
)
Two-point discrimination static/ dynamic (mm)
Prick test Pain threshold (g/mm 2 ) Sharp/smooth discrimination Hot/cold discrimination Flap Contralateral/non-operated mucosa Flap
Contralateral/non-operated mucosa Flap
Contralateral/non-operated mucosa 1
F/58 years
Yes 0.354 0.354 8/5 6/5 Yes 732.8 102.5 Yes Yes
2
M/76 years
Yes 0.372 0.354 5/4 4/3 Yes 279.16 62.5 Yes Yes
3 F/54 years
Yes 1.282 0.372 12/10 7/5 Yes >732.8 104.6 Yes Yes
4
M/67 years
Yes 0.354 0.354 8/5 4/3 Yes 289.89 61.8 Yes Yes
5
M/50 years
Yes 0.372 0.354 7/5 5/4 Yes 279.16 61.8 Yes Yes
6
M/59 years
Yes 0.372 NR 8/5 NR Yes 279.16 NR Yes Yes
7
M/61 years
Yes 1.282 0.354 10/7 6/5 Yes 732.8 102.5 No Yes
8
M/56 years
Yes 1.282 0.372 22/15 7/5 Yes 732.8 102.5 No No
9
M/63 years
Yes 0.372 0.354 11/9 4/4 Yes 279.16 61.8 Yes Yes
10 M/64 years
Yes 0.372 0.354 8/6 5/4 Yes 279.16 61.8 Yes Yes
11 F/58 years
Yes 0.354 0.354 8/7 4/3 Yes 279.16 62.5 Yes Yes
12 M/72 years
Yes 0.372 0.372 9/6 7/4 Yes 732.8 62.5 Yes Yes
13 M/72 years
Yes 1.282 NR 7/7 NR Yes >732.8 NR Yes Yes
14 F/75 years
Yes 1.282 0.372 9/7 6/5 Yes >732.8 102.5 Yes Yes
15 M/54 years
Yes 0.354 0.354 10/8 7/5 Yes 279.16 102.5 Yes Yes
16 M/62 years
Yes 1.282 1.282 21/15 18/9 Yes >732.8 102.5 No No
17 F/70 years
Yes 0.372 0.354 9/8 6/5 Yes 732.8 102.5 Yes Yes
Total 100% 0.689 0.451 0.42 0.238 10.1 4.6/
7.5 3.2
6.4 3.4/ 4.6 1.4
100% 519.95 232.72 83.79 21 82.3% 88.2%
Statistical analysis Wilcoxon test Z = 2.85 P = 0.004 Wilcoxon test Static: Z = 3.43, P = 0.001 Dynamic: Z = 3.31, P = 0.001 Wilcoxon test Z = 3.44 P = 0.001 F, female; M, male; NR, not reported (patients with defects involving the whole soft palate).
keepinganobturatorstill,sosideeffects suchasmucositisandtrismusmayreduce patient compliance overtime18. Further-more,patientswithsoftpalateobturators haveshownreducedspeechintelligibility in comparison with patients who have receivedasofttissuereconstruction4.
Nowadays, soft tissue transfer is pre-ferredtoobturatorsforthemanagementof most soft palate defects. Various local flaps, suchasbuccalfatpad,buccal mu-cosa,andpalataladvancementflaps,have beenutilizedsuccessfullyforthe restora-tion of small lateral defects of the soft palate4–6.
Regional flaps such as the pectoralis major, latissimus dorsi, temporalis mus-cle,and temporalmyocutaneousflapare necessarytodealwiththelargerdefects7–
9
.Theseflaps providealargeamountof tissue,buttheyareaffectedbygravitydue totheirbulk.Furthermore,positioningis difficult because of their stiffness, and they lack sensation, resulting in speech andswallowingdifficulties27.
Forthesereasons,fasciocutaneous mi-crosurgical freeflaps representthe tech-nique of choice for soft palate reconstruction.Freeflapshavethe advan-tagesofreliablevascularization,
simulta-neous flap elevation with tumour resection,andwideversatility.Theradial forearmflapisthefirstchoice11,13–15.The thin,pliablenatureofthisfasciocutaneous flapissuitedtoreplacetheoropharyngeal mucosa,butitmight shrinkduring heal-ing, especially after postoperative radio-therapy, increasing the posterior oropharyngeal space and reducing soft palate mobility.Theseeffectsmayresult in velopharyngeal incompetence, nasal speech,andnasalregurgitation.To over-come these disadvantages, many efforts havebeenmadetostandardizetheforearm flap design13,14,28,29. In2013, Massarelli et al.describedthe double-layer restora-tionofasoftpalatedefectusingasingle ‘folded’tunnelizedfacialartery myomu-cosal island flap (t-FAMMIF), which allows mucosal resurfacing of both the oralandthenasallining18(Table1, case 4).
Buccinatormyomucosalflapspedicled onbranchesofthedensevascularnetwork betweenthefacialarteryandtheinternal maxillaryarteryconformtothe‘likewith like’ reconstruction principle, because they containthin, mobile, well-vascular-ized,andsensitivetissue,likethatexcised orlost.Thepediclelengthandtunnelling technique increase the versatility of the flap,whichcanbeusedtoproperlyrestore even contralateral or total soft palate defects(Fig.3).
Aslocalflaps, buccinatormyomucosal flapscanbereadilyandquicklyharvested fromthesamesurgicalfieldasthedefect, reducing theoperativetime.Theydonot
Softpalatefunctionalreconstruction
Table3.Resultsofthedeglutitionassessment;thescorerangesfrom1(severecomplaintsand unabletoswallow)to7(nocomplaints)24.
Patientnumber Sex Age,years Deglutitionscore
1 F 58 6 2 M 76 7 3 F 54 5 4 M 67 7 5 M 50 6 6a M 59 7 7 M 61 6 8 M 56 5 9 M 63 6 10 M 64 7 11 F 58 6 12 M 72 5 13 M 72 7 14 F 75 7 15 M 54 6 16 M 62 6 17 F 70 4 Total(meanSD) 6.10.9
F,female;M,male;SD,standarddeviation.
a
SeeSupplementaryMaterial,Video1.
Table4. Resultsofthequalityoflifeassessment:FunctionalAssessmentofCancerTherapy HeadandNeckquestionnaire(FACT-H&N).For eachdomain,theoverallscoreisgivenasthesumoftheindividualitemscores;theserangefrom0(severedeteriorationoftheitemassessed)to4 (nodeteriorationoftheitemassessed)25.
Patientnumber Sex Age(years)
Physicalwell-being (range0–28) Social/family well-being (range0–28) Emotional well-being (range0–24) Functional well-being (range0–28) H&N cancersub-scale (range0–40) 1 F 58 27 28 21 26 40 2 M 76 28 25 21 25 40 3 F 54 23 10 8 18 34 4 M 67 27 28 24 28 40 5 M 50 28 28 24 27 38 6 M 59 26 28 24 27 40 7 M 61 15 18 16 22 33 8 M 56 20 26 18 20 34 9 M 63 26 25 21 25 39 10 M 64 25 27 23 26 38 11 F 58 24 27 23 27 38 12 M 72 26 28 22 26 38 13 M 72 27 28 23 28 40 14 F 75 27 28 21 26 39 15 M 54 26 25 15 27 33 16 M 62 23 25 11 24 34 17 F 70 20 21 9 17 35 Total(meanSD) 24.63.5 254.8 19.15.4 24.63.4 37.22.3 F,female;M,male;SD,standarddeviation.
require two surgical teams, they entail shorter operating times, and they cause lessdonorsitemorbidity,withnoevident scar16–19. Trismus mayoccur dueto the donorsitescar,butitcanbeavoidedwith postoperative massages of the area and using the advancement of a buccal fat padduringdonorsiteclosure.
Moreover, satisfactory functional and aesthetic results were reported for these myomucosal flaps (Tables 2–5). All patientsexperiencedgoodrecoveryofflap sensitivity (Table 2). These excellent results, even better than those reported forfasciocutaneousreinnervatedfreeflap
reconstructions30,31,mayberelatedtothe low fibrotic retraction of the buccinator muscle, which favours nerve sprouting fromthesurroundingtissues.
All patients started speech rehabilita-tiontherapyafternasogastrictube remov-al, achieving satisfactory recovery of speech (Supplementary Material, Video 1)andswallowing(Table3).The restora-tionoftheseoropharyngealfunctionsled thepatientstoreportasatisfactory percep-tionoftheirQoL(Table4).
Inconclusion, the buccinator myomu-cosalislandflapappearstobeaversatile andusefulreconstructivemethodbecause
ofitsintrinsic characteristics,andmerits consideration with regard to reconstruc-tive surgery for extensive soft palate defects. Obviously, this study presents some limitations due toits retrospective nature, the small number of patients assessed,andthelackofacontrolgroup reconstructedwithothertechniques(e.g., forearmfreeflaps). It is plannedto per-formfurtherprospectivestudies to com-parethefunctionaloutcomesofdifferent typesofsoftpalatereconstruction in ho-mogeneousgroups ofpatients,either by tumourcharacteristics,orintermsof treat-mentmodalities.
Table5. Donorsitemorbidityassessment(performedbytwocliniciansandthepatient).Foreachparameter,thescorerangesfrom0(severedonor sitemorbidity)to3(nodonorsitemorbidity)26.
Patientnumber Sex Age(years)
Mouthopening (range0–9) Commissuresymmetry (range0–9) Innervestibule (range0–9) Cheeklining (range0–9) Aesthetics (range0–9) 1 F 58 9 9 9 9 9 2 M 76 9 9 9 9 9 3 F 54 6 7 8 9 8 4 M 67 9 7 9 9 9 5 M 50 9 9 9 9 9 6 M 59 9 8 9 9 9 7 M 61 6 5 6 7 6 8 M 56 6 8 8 7 5 9 M 63 9 9 8 8 9 10 M 64 9 8 9 8 9 11 F 58 9 9 8 8 8 12 M 72 9 9 9 8 9 13 M 72 9 9 8 9 9 14 F 75 6 7 8 7 7 15 M 54 9 8 8 8 8 16 M 62 6 7 9 7 8 17 F 70 6 8 8 8 8 Total(meanSD) 7.91.5 81.1 8.30.8 8.20.8 8.21.2 F,female;M,male;SD,standarddeviation.
Fig.3. Case6,a59-year-oldmalepatient.(A)Totalsoftpalatedefectfollowingtumourablation.(B)Atunnelizedfacialarterymyomucosal islandflap(t-FAMMIF)washarvestedfromtherightcheek.(C)Theflapwassuturedattherecipientsitetoreconstructthesoftpalateandthetwo tonsillarlodges.(D)Follow-upat16months.
Funding None.
Competinginterests None.
Ethicalapproval
EthicalapprovalwasgivenbytheEthics Committee of the University of Sassari (Ref.No.69/2016).
Patientconsent
Written consent was obtainedto publish theclinicalphotographs.
AppendixA. Supplementarydata Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.ijom. 2017.11.012.
References
1. Mu¨ckeT,KoschinskiJ,WagenpfeilS,Wolff KD, Kanatas A, Mitchell DA, Deppe H, KestingMR.Functionaloutcomeafter dif-ferentoncologicalinterventionsinheadand neck cancer patients. J Cancer Res Clin Oncol2012;138:371–6.
2. Seikaly H,RiegerJ,ZalmanowitzJ,Lam TangJ,AlkahtaniK,AnsariK,O’ConnellD, Moysa G,Harris J.Functionalsoft palate reconstruction:acomprehensivesurgical ap-proach.HeadNeck2008;30:1615–23.
3. Bohle3rdG,RiegerJ,HurynJ,VerbelD, HwangF,ZlotolowI.Efficacyofspeechaid prosthesesforacquired defectsofthesoft palate and velopharyngeal inadequacy— clinicalassessmentsandcephalometric anal-ysis: a Memorial Sloan-Kettering Study. HeadNeck2005;27:195–207.
4. GillespieMB,EiseleDW.Theuvulopalatal flap for reconstruction of the soft palate. Laryngoscope2000;110:612–5.
5. GendenEM,LeeBB,UrkenML.Thepalatal islandflapforreconstructionofpalataland retromolar trigone defects revisited. Arch
Otolaryngol Head Neck Surg
2001;127:837–41.
6. BaumannA, EwersR.Applicationof the buccalfatpadinoralreconstruction.JOral MaxillofacSurg2000;58:389–92.
7. KiyokawaK,TaiY, TanabeHY,InoueY, Yamauchi T, Rikimaru H,MoriK, Naka-shimaT.Amethodthatpreservescirculation during preparationofthepectoralismajor myocutaneousflapinheadandneck recon-struction. Plast Reconstr Surg 1998;102:2336–45.
8. Bradley P, Brockbank J. The temporalis muscleflapinoralreconstruction.A cadav-eric,animalandclinicalstudy.JMaxillofac Surg1981;9:139–45.
9. DavidJM,PaoliJR,BejjaniW,BonnetF, BachaudJM,BarthelemyI.Atemporal fas-cio-cutaneous island flap in the mucosal reconstruction of the oropharynx and the mouth after oncologic surgery. A propos of22cases.RevStomatolChirMaxillofac 1994;95:313–8.
10. CivantosJrFJ,BurkeyB,LuFL,Armstrong W.Lateralarmmicrovascularflapinhead andneckreconstruction.ArchOtolaryngol HeadNeckSurg1997;123:830–6.
11. PenfoldCN,BrownAE,LaveryKM,Venn PJ.Combinedradialforearmandpharyngeal flapforsoftpalatereconstruction.BrJOral MaxillofacSurg1996;34:322–4.
12. Michiwaki Y, Schmelzeisen R, Hacki T, MichiK.Functionaleffectsofafreejejunum flapusedforreconstruction inthe oropha-ryngeal region. J Craniomaxillofac Surg 1993;21:153–6.
13. KimJH,ChuHR,KangJM,BaeWJ,OhSJ, Rho YS, Ahn HY, Jung CH. Functional benefitaftermodificationofradialforearm freeflapforsoftpalatereconstruction.Clin ExpOtorhinolaryngol2008;1:161–5.
14. KimataY,UchiyamaK,SakurabaM, Ebi-haraS,HayashiR,HanedaT,OnitsukaT, AsakageT,NakatsukaT,HariiK. Velophar-yngeal functionafter microsurgical recon-struction of lateral and superior oropharyngeal defects. Laryngoscope 2002;112:1037–42.
15. SeikalayH,RiegerJ,ZalmanowitzJ,Tang JL, AlkathaniK,Ansari K,O’Connell D, MoyosaG,HarrisJ.Functionalsoftpalate reconstruction:acomprehensivesurgical ap-proach.HeadNeck2008;30:1615–23.
16. MassarelliO,GobbiR,RahoMT,TullioA. Three-dimensional primary reconstruction ofanteriormouthfloorandventraltongue using thetrilobed buccinator myomucosal island flap. Int J Oral Maxillofac Surg 2008;37:917–22.
17. Massarelli O, Baj A,Gobbi R, Soma D, MarelliS,DeRiuG,TullioA,Giannı` AB. Cheek mucosa: a versatile donor site of myomucosalflaps.Technicalandfunctional considerations.HeadNeck2013;35:109–17.
18. MassarelliO,GobbiR,SomaD,TullioA. Thefoldedtunnelized-facialartery myomu-cosalislandflap:anewtechniquefortotal softpalatereconstruction.JOralMaxillofac Surg2013;71:192–8.
19. MassarelliO,VairaLA,BiglioA,GobbiR, PiombinoP,DeRiuG.Rationaland simpli-fiednomenclatureforbuccinator myomuco-salflaps.OralMaxillofacSurg2017.http:// dx.doi.org/10.1007/s10006-017-0655-9. 20. VairaLA,MassarelliO,GobbiR,SomaD,
Dell’aversanaOrabonaG,PiombinoP, De RiuG.Evaluationofdiscriminative sensibil-ityrecoveryinpatientswithbuccinator
myo-mucosalflaporalcavityreconstructions.Eur JPlastSurg2017.http://dx.doi.org/10.1007/ s00238-017-1277-z.
21. MassarelliO,VairaLA,DeRiuG.Islanded facialarterymusculomucosalflapfortongue reconstruction. IntJ OralMaxillofacSurg 2017;46:1060–1.
22. KomiyamaO,GracelyRH,KawaraM,Laat AD. Intraoral measurement of tactile and filament-prick pain thresholdusing short-ened Semmes–Weinstein monofilaments. ClinJPain2008;24:16–21.
23. VairaLA,MassarelliO,MeloniSM, Dell’a-versanaOrabonaG,PiombinoP,DeRiuG. Alveolarnerveimpairmentfollowing bilat-eralsagittalsplitramusosteotomyand gen-ioplasty.JOralMaxillofacSurgMedPathol 2017;29:203–9.
24. TeichgraeberJ,BowmanJ,GoepfertH.New testseries forthefunctionalevaluation of oral cavity cancer. Head Neck Surg 1985;8:9–20.
25. D’AntonioLL,ZimmermanGJ,CellaDF, Long SA. Quality of life and functional status measuresin patientswith headand neckcancer.Arch OtolaryngolHeadNeck Surg1996;122:482–7.
26. FerrariS,FerriA,BianchiB,CopelliC,Boni P,SesennaE.Donorsitemorbidityusingthe buccinator myomucosal island flap. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2011;11:306–11.
27. SabriA.Oropharyngealreconstruction: cur-rentstateoftheart.CurrOpinOtolaryngol HeadNeckSurg2003;11:251–4.
28. LewDH,ChoiEC,TarkKC.Standardization offlapdesignfororopharyngeal reconstruc-tion after cancer ablation surgery. Yonsei MedJ2003;44:1078–82.
29. BiglioliF,BrusatiR.Thefoldedradial fore-armflapin soft-palateandtonsillaryfossa reconstruction: technical note. Int J Oral MaxillofacSurg2008;37:76–81.
30. BiglioliF,LivieroF,FrigerioA,Rezzonico A,BrusatiR.Functionofthesensatefree forearm flap after partial glossectomy. J CraniomaxillofacSurg2006;34:332–9.
31. LoewenIJ,BoliekCA,HarrisJ,SeikalyH, RiegerJM.Oral sensationand function:a comparisonofpatientswithinnervated radi-alforearmfreeflapreconstructiontohealthy matchedcontrols.HeadNeck2010;32:85– 95.
Address:
LuigiAngeloVaira MaxillofacialSurgeryUnit UniversityHospitalofSassari VialeSanPietro43/B 07100Sassari Italy
Tel.:+393401846168 Fax:+39079229002 E-mail:luigi.vaira@gmail.com
