British .~ournalof Plastic Surgery (1977), 30, 17-37
MAXILLO-FACIAL
AND PALATAL RECONSTRUCTIONS DELTOPECTORAL FLAP
By V. Y. BAKAMJIAN, M.D. and MICHAELPOOLE, F.R.C.S., Department of Head and Neck Surgey, Roswell Park Memorial New York 14.263, USA
WITH
THE
F.R.A.C.S.l
Institute, 666 Elm Street, Buffalo,
It is generally agreed that successful treatment of cancer involving the maxillary antrum usually requires surgical excision, whether alone or in combination with radiation therapy. Because cancer can remain occult for a long time in the bony confines of the region and not become evident until well advanced, such surgery is often radical. It may create a widely open defect with awesome proportions which may extend from the mouth to the dura vertically and from in front of the ear to the midline or further horizontally. If one is to have the courage to attempt the necessary resection, and if the unfortunate patient is to be willing to submit to the proposed treatment, prompt measures for dependable reconstruction are imperative for countering the dire implications of facial mutilation and oral dysfunction to the best possible degree. Formerly, a technique described by one of us (Bakamjian, 1963) for palatal restoration after radical maxillectomy was used extensively at the Roswell Park Memorial Institute in instances where the extent of the loss of supporting structures made impractical a satisfactory obturationof the palatal defect withaprosthesis. The methodused a lengthened modification of Owens’ (1955) compound flap of cervical skin and sternocleidomastoid muscle, including the muscle solely for the purpose of assuring viability without a preliminary delay. Valid and dependable in terms of the reconstruction, the
FIG. I. Case I. A and B, This women of 6g years sought relief from excruciating pain from this cancerous and radionecrotic lesion which had extensively destroyed tissues on the left face, nose, supra-orbital region and the eye, and had skeletonised the orbit and maxilla. Biopsy disclosed basal cell carcinoma, as well as some elements of squamous cell cancer in the inferior and lateral parts of the lesion. 1 Present England.
30/1-B
address: Middlesbrough
General Hospital,
I7
Ayresome
Lane,
Middlesbrough,
Cleveland,
18
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FIG. 2. Case I. A, After initial clearing by Mohs’ chemosurgery technique, limited to the margin area that was threatening the safety of the remaining eye, a radical resection was performed. This did not encompass the chemosurgically cleared portions at the glabellar and nasal areas. leavine them for excision at a later time, and it did not have to include the roof of the mouth. The temporalis muscle was dissected free from its origin on the squamous portion of the temporal bone and (B) rotated to cover exposed dura and irregular bony surfaces in the upper half of the defect. FIG. 3. Case I. A split-thickness skin graft covered the muscle flap and a deltopectoral flap (without delay) was used to cover the remainder of the defect.
FIG.4. Case I. After healing and I delay procedure on the base of the deltopectoral flap, the chemosurgically treated nasal and glabellar areas were also resected with exenteration of the tumour containing frontal sinus walls, and the flap base was transferred to cover the defect.
MAXILLO-FACIAL
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FIG. 5. Case I. A and B, In 2 final revisions the flap was divided at its middle and smoothed out on the face, leaving a fistula near the nasal region which could provide support for a facial prosthesis. Such a prosthesis was to be constructed, but relieved of her pain and satisfied with the result, the patient returned to her home town in the state of Maine and never returned for follow-up.
Fig. 6. Case 2. This man of 62 years came with an aggressive squamous cell cancer persisting after treatment which had completely destroyed his nose. He had had 12 operations and 4 courses of radiation treatment all to no avail. Already invading in the medial portions of the right orbit and maxilla, the cancer was also threatening to enter the left orbit. FIG. 7. Case 2. After exploring chemosurgically by Mohs’ technique the medial canthal It included remnants tain the safety of the left eye, a radical resection was performed. nasal septum, ethmoids and cribriform plate bilaterally, in addition to the right frontal maxilla, but the roof of the mouth was intact. Dura over an area of 6 x 6 cm was exposed roof of the defect.
region to ascerof the nose, the sinus, orbit and medially in the
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technique was open to criticism necessary later; nor is the flap applicable in of fixed or even nodal metastases in the neck. This pictorially presented report on a series of 7 maxillofacial resection cases illustrates approach, not subject to the same criticism, using in some differing
the
FIG. 8. Case 2. A and B, An extra long undelayed deltopectoral flap with a large deltoid paddle was used to cover the exposed dura and other raw surfaces in the wound. Unfortunately, however, a faint cyanosis in the deltoid portion began to proceed after 24 hours to a purple mottling and eventually to mummification by necrosis.
FIG. g. Case 2. Debridement was performed after I week and the granulating wound was grafted successfully with split-thickness skin after another week. At last report, 24 years after the resection, no tumour recurrence had occurred locally, but a shadow on chest X-ray was suggestive of either a metastasis or another primary in the lung.
MAXILLO-FACIAL
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FIG. IO. Case 3. A and B, This young man of rg years had a massive tmnour expanding the right maxillary antrum which had obliterated the right eye, filled rhe right nasal chamber with a fleshy mass, and The histology was that of an osteogenic sarcoma. bulged via the palate into the roof of the mouth.
FIG.
II. Case 3. Right orbito-maxillary resection included skin of the right cheek, anterior wall of the frontal sinus, the ethmoidal labyrinth, and a little more than the right half of the hard palate.
FIG. IZ.
Case 3.
A long large right deltopectoral
flap was raised without preliminary
delaying.
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FI G. 13. Case 3. A and B, The flap was tunnelled subcutaneously through an upper neck incision, passing on the outer side of the mandible, to close the palatal defect, epithelial side facing orally and raw side facing uFIward. Within the tunnel the flap was tubed in inverse manner to avoid opposing skin to the raw surfaces in the passage, and outside the tunnel it was tubed in the opposite direction, epithelium facing outward. A split-thickness skin graft was then applied to the upward-looking raw surface of the part forming the new roof of the mouth. FIG. 14.
Case 3.
A and B, Excepting a minor suture line separation between flap and mucoperiosteal edge of the palate, complete healing was achieved.
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FIG. 15. Case 3. After I delay procedure, the tubed segment of the flap was transposed on to the nasal septum, after removing its secretory mucous membrane. One month later, because of a positive biopsy from the fronto-ethmoidal region, 5,000 r radiation therapy was given over 30 days with good response. FIG. 16. Case 3. Two months after the fnst operation the tube of the pedicle was divided at its middle, the tunnelled portion was excised to close the fistula, and the remainder was applied to cover more of the posterior wall of the facial defect. Unfortunately about 6 months after this he succumbed to recurrent disease at the base of the skull, metastases, and a solid core of tumour growing down the right jugular vein into the heart. Death was attributed to right heart failure from extensive embolisation into the pulmonary arteries.
FIG. 17. Case 4. A and B, A 6o-year-old woman with an advanced maxillary cancer surfacing at the infraorbital and medial canthal region of the right eye and bulging with ulceration into the roof of the mouth.
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20 FIG. 18. Case 4. Radical orbito-maxillary resection included also the skin of the cheek and the masticatory muscles which had been infiltrated grossly with the tumour in the pterygoid fossa. FIG. 19. Case 4. As in case 3, a right undelayed deltopectoral flap was introduced by subcutaneous tunnelling and bi-directional tubing into the defect, but instead of forming the palate it was used as protective lining for exposed dura and raw surfaces in the defect. Radiotherapy followed after I week in view of the gross infiltration with tumour of the removed muscles and it was carried to a dose of 5,000 r in a period of S weeks. FIG. 20.
Case 4.
With
the flap healed and radiotherapy completed, secondary closure.
the palatal defect
remained
for
FIG. 21. Case 4. The tubed pedicle was divided at its base and the tunnelled segment was dissected free. By pulling it into the mouth and folding the pedicle on itself, the palate was reconstituted. Joining together the limbs of the folded tube in a subsequent stage completed the palatal closure, and a right-neck dissection was performed at the same time because a small mass had appeared in the submandibular area. This proved to be tumour in soft tissue around the submandibular salivary gland but none of the 34 lymph nodes examined were found to contain cancer.
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Case 4. She can now eat by mouth and speaks understandably with some degree of nasality. Close to 2 years after the resection, a small but deep recurrence has become evident behind and on the inner side of the mandibular angle on the right side.
FIG. 22.
FIG. 23. Case 5. A and B, This women of 56 years came with an excisional defect of the upper lip and the left orbito-maxillary region that contained recurrent adenoid-cystic carcinoma on all walls of the defect and a large nodule at the base of the right ala nasi. She gave a history of 5 resections and 2 courses of radiation therapy in over IO years, and most recently some chemotherapy and immunotherapy, all to no avail. Bilaterally, enlarged nodes were evident in the upper neck, and radiotomograrns showed lytic changes in the ethmoids and in the greater wing of the sphenoid bone. She was desperate for any treatment that could alleviate her obvious sufferings.
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FIG. 24. Case 5. A monobloc resection, mainly with intent to palliate, was attempted, knowing full well that cure was beyond any reasonable likelihood. It removed the nose, bilaterally the ethmoids and cribriform plate, the nasal septum, remnants from the previous orbito-maxillary resection on the left side, the medial half of the right maxtlla, and all of the palate excepting a short alveolar segment on the right side with z molar teeth. Torn in 2 places, the exposed dura was closed by suture.
FIG. 25.
Case 5. A and B, The left temporal muscle, released from its origin, was tunnelled subcutaneously into the defect and used to cover and buttress the repaired dura.
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Case 5. A, B and C, A large paddled and long deltopectoral flap was raised without preliminary delay. Tunnelled subcutaneously with bidirectional tubing as in the previous cases, the flap was used to line all parts of the excisional defect.
FIG.
28
FIG.
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27.
FIG. 28.
Case 5.
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Healing was complete after recovery from a bout of meningitis antibiotics administered intrathecally.
which responded
to
Case 5, Divided from the chest, freed, from the subcutaneous tunnel and delivered into the facial defect, the tubed segment was used to restore palate and upper lip.
FIG. 29. Case 5. A and B, After a right neck dissection, modified by not removing the internal jugular vein and stemomastoid muscle, and a left supra-omohyoid neck dissection, a couple of minor revisions improved her appearance and her oral function. A skin-lined fistula from the nasal region to the centre of the rather flaccid palatal reconstruction was created for the purpose of wearing a prosthesis made of z components: a nasal component, and a tooth-bearing palatal component which could be snapped together with a connecting rod passed through the fistula. The patient however, pleased with the results from She has passable speech and eats by mouth. surgery, chose not to bother wearing the prosthesis. A shadow on X-ray in her right lung field has shown some growth on last report about I& years after the resection, but she remains asymptomatic and well palliated.
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FIG. 30. Case 6. This man of 6g years complained of pain in a huge mass of recurrent melanoma in and on the right maxilla which had obliterated the right eye, blocked the right nasal chamber, infiltrated into the right half of the upper lip, and perforated through the palate into the roof of the mouth. He gave a history of 4 resections and an intra-arterially administered course of chemotherapy without benefit shortly before coming to the Roswell Park Memorial Institute. FIG. 31. Case 6. Without any hope for cure, a proposal for palliative orbito-maxillary resection, including upper lip, skin of the cheek, parotid gland and ascending ramus of the mandible, was readily accepted by the patient. Tumour was encountered penetrating via the inferior orbital fissure and optic foramen into the cranial cavity.
FIG. 32.
Case 6. With merely a skin graft to cover raw parts, the defect was left open, making no elaborate initial attempt to reconstruct.
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Case 6. A and B, A right deltopectoral flap was delayed, folding at a right angle an extension of skin from the upper arm under the deltoid portion, thus providing the 2 layers necessary for the intended reconstruction.
FIG. 33.
FIG. 34.
Case 6. A and I$ Thus prepared the folded flap was moved into the facial defect to reconstitute the palate and missing half of the upper lip and restore his ability to eat and to speak.
31
FIG. 35. Case 6. A and B, Approximately 2 months after another stage to supplement the reconstruction by moving the tubed base of the flap into the facial defect, the patient began showing signs of intracranial involvement, gradually progressed into semicoma, and succumbed to terminal bronchopneumonia I year and 2 months after the major resection. FIG. 36. Case 7. This patient of 56 years had a poorly differentiated carcinoma of the right maxillary antrum in an advanced stage, persisting after a radiotherapy course of 6,000 r, and infected and draining pus after an attempted resection had been abandoned because the surgeon, in reflecting the cheek flap for exposure, had encountered tumour outside the bony confines of the antrum and had judged it to be non-resectable. FIG. 37. Case 7. At Roswell Park Memorial Institute, while receiving a course of chemotherapy with Bleomycin, a right deltopectoral flap was delayed with an extension of skin from the upper arm folded under the deltoid portion, as in the previous case.
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FIG. 38. Case 7. A and B, Radical orbito-maxillary resection including the skin of the cheek, the ethmoid labyrinth, pterygoid laminae and muscles, and the anterior half of the ascending ramus of the mandible.
FIG. 39. Case 7. For the immediate first step of reconstruction the prepared flap was moved into the defect, setting the single layer of its distal-most end against the nasal septum such that the doubled portion formed the roof of the mouth. FIG. 40.
Case 7.
Four weeks later the base of the well-healed flap was divided and implanted superiorly into the defect.
postero-
MAXILLO-FACIAL
FIG. 41.
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Case 7. A and B, After another 4 weeks the now U-shaped flap was divided at its middle and its tubed posterior limb was opened upwards. C and D, The upper layer of its anterior limb was rolled backwards, forming a skin-lined tube from the region of the nasal root to the nasopharnyx, and the opened posterior limb was then brought down to close the cheek.
3011-c
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FIG. $2. Case 7. A and B,.The fistula at the side of the nasal root was purposely left open for toilet with irrigations to keep the &m-lined facial cavity clean, and also as anchorage for an ocular prosthesis. FIG. 43.
Case 7.
With the palate well restored, the patient is able to eat and speak normally and has remained free of cancer for more than 5 years since the resection.
MAXILLO-FACIAL
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even in some situations appearing utterly hopeless, with radical surgery and expeditious reconstruction the surgeon and patient may be pleasantly surprised by an unexpected cure (as in case 7). Many a time, moreover, even if the hoped for cure proves impossible to obtain, palliation worth the effort is achieved with this approach, either obtaining a long-term control of local disease (as in case 5), or by ridding the patient of pain in a fast-expanding turnour mass (as in cases 3 and 6), or by eliminating an ulcerated, painful, easily bleeding, fungating and malodorous lesion (as in cases I and 5). In some there may even result improvements in function and appearance, albeit only for the patient’s limited remaining life. Concerning rehabilitation by prostheses it has been said that the efficiency is inversely proportional to the size of the defect the appliance closes (Longacre and Gilby, 1954). In radical maxillary resections with orbital exenteration and cheek resection such as those presented, the defect is indeed large and not well amenable to rehabilitation with a prosthesis. Active movements of the lower jaw and the extent of loss of teeth and other supporting structures in the upper jaw and face make the satisfactory fitting and wearing of a prosthesis, even to obturate the palatal defect, a major problem. The patients, moreover, usually find such a prosthesis, that requires frequent removal and cleaning, to be more of a nuisance than a help. The requirements of full surgical rehabilitation after a radical orbito-maxillary resection are threefold; immediate provision of adequate protective covering for raw wounds, bared bone and exposed dura or brain, closure of the palatal defect for oral function, and some form of masking and contour filling for the hollow orbito-facial defect to make the final appearance inoffensive. Most previous methods of repair tend to leave one or more of these requirements relatively not satisfied. Split skin grafts are commonly used to line the orbito-facial defect. Their relative inadequacy in protecting bare bone, dura or brain, their inability to close the palatal defect, or fill the facial contour, are self-evident. Flaps can serve better and temporal scalp flaps (Campbell, 1954) and forehead flaps (Stark, 1962; Thompson, 1970) have been used, but these procedures often result in unsightly scarring of the forehead. Alternatively, any exposed orbital bone and dura can be adequately protected and the orbital hollow can be filled with the temporalis muscle used as a flap (Naquin, 1956; Webster, 1957; Reese, 1958; Bakamjian and Souther, 1975). The muscle flap in turn can be covered with local eyelid skin, when this is available, or with a split skin graft (as in the case I) or with another flap (as in case 5). Reconstruction of the palatal loss after maxillectomy was probably first described by Foederl in 1903, although there are earlier reports of repair of other palatal defects using a forehead flap in 1869 and cheek tissues in 1867 (Longacre and Gilby, 1954). Foederl used an inferiorly based flap of nasal septum. Since than many methods of surgical palate repair have been described, including tubed skin pedicles (Padgett, 1936; Kostrubala, 1950; Edgerton and Zovickian, rg56), septal flap (Edgerton and Devito, 1963), Owens’ compound cervical flap (Bakamjian, rg63), and even a free jejunal transfer by vascular anastomosis (Black et al., 1971). A more or less comprehensive satisfaction of all 3 of the above mentioned reconstructive requirements is possible with the deltopectoral flap in a flexible variety of ways
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as is well demonstrated, particularly in cases 5 and 7; in addition to protective covering and palate closure, the large bulk of subcutaneous tissue and skin available with the deltopectoral flap allowed satisfactory contour filling for reconstruction of the orbitofacial defect as well. In other cases a fairly acceptable cheek defect was left, which could either adequately support wearing an external prosthesis (as in cases I and 3) or could be additionally repaired surgically with another flap. The question arises as to whether the flap is to be delayed before it is transferred. In the last 2 of this series it was-delayed for the purpose of giving a dual skin surface to its deltoid end by underfolding an extension at a right angle to it from the skin of the upper arm. In both instances the flap was successful. In the remaining 5 cases in which a delay was not used I extra large flap in a male patient failed (case 2), but flaps with comparable dimensions succeeded in 3 elderly females (cases I, 4 and 5), and also in I young male (case 3). This may be taken to suggest that when extended to beyond average dimensions the flap may prove relatively more reliable in female patients than in males, particularly in women who have lactated, because of a better developed internal mammary system of blood vessels. Finally, other variations in the manner of using the flap may be noted. In cases I, 2, 6 and 7 the first move of the flap was made directly into the opening of the orbitofacial defect by an external route, with tubing of the bridge segment. This provided protective covering in case I but failed to do so in case 2, and it restored the palate first in cases 6 and 7 with its previously folded end. In the remaining 3 cases the flap entered to its destination via a subcutaneous tunnel in the upper neck with the bridge segment tubed, skin-in within the tunnel and skin-out in its external course. In case 3 the flap went initially to restore the palate and its pedicle was subsequently moved into the Conversely, in cases 4 and 5 the orbitofacial defect to supplement the reconstruction. flap went initially to line the orbitofacial defect and its pedicle was subsequently used for restoration of the palate.
SUMhlARY
A flexible method for reconstruction of the defects resulting from radical orbitomaxillary resections is described with 7 illustrative case reports, using the deltopectoral flap.
REFERENCES
BAKAMJIAN,V. Y. (1963). A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plastic and Reconstructive Surgery, 31, 103. BAKAMJIAN,V. Y. and SOLJTHER, S. G. (1975). Use of temporal muscle flap for reconstruction after orbito-maxillary resections for cancer. Plastic and Reconstructive Surgery, 56, 171. BLACK,P., GRISWALD,B. A. and ARNOLD,P. G. (1971). One-stage palate reconstruction with a free neo-vascularized jejunal graft. Plastic and Reconstructive Surgery, 47, 316. CAMPBELL,H. H. (1954). Surgery of lesions of the upper face. American Journal of Surgery,
87, 676.
EDGERTON,M. T. and DEVITO, R. V. (1963). Closure of palate defects by means of a hinged nasal septum flap. Plastic and Reconstructive Surgery, 31, 537. EDGERTON,M. T. and ZOVICXIAN,A. (1956). Reconstruction of major defects of the palate. Plastic and Reconstructive Surgery, 17, 105. FOEDERL,0. (1903). Ueber gaumenplastik aus der nasenscheidewand. KOSTRUBALA, J. G. (1950). Repair of extensive palatal defects with skin tubes. Plustic and Reconstructive Surgery,
5, 512.
LONGACRE,J. J. and GILBY, R. F. (1954). The problem of reconstruction of extensive severely scarred palatal defects in edentulous patients. Plastic and Reconstructive Surgery,
14, 357.
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NAQUIN, H. (1956). Orbital reconstruction utilizing temporalis muscle. American Journal of Ophthalmology, 41, 519. OWENS, N. (1955). Compound neck pedicle designed for the repair of massive facial defects. Plastic and Reconstructive Surgery,
IS, 369.
PADGETT,E. (1936). The repair of cleft palate primarily unsuccessfully operated upon. Surgery, Gynecology and Obstetrics, 63, 483. REESE, A. B. (1958). Exenteration of the orbit: with transplantation of the temporalis muscle. American Journal of Ophthalmology, 45, 386. STARK,R. (1962). “Plastic Surgery”, p. 235. New York: Harper and Row. THOMPSON, H. (1970). Reconstruction of the orbit after radical exenteration. Plustic and Reconstructive Surgery, 45, I t9. WEBSTER,J. P. (1957). Temporalis muscle transplants for defects following orbital exenteration. “Transactions of the First International Congress on Plastic and Reconstructive Surgery”, p. 291. Baltimore: Williams and Wilkins Company. Figures I, 2,3 and 5 are republished with the Editor’s permission from Bakamjian, V. Y. and Souther, S. G.: Use of temporal muscle frap for reconstruction after orbito-maxillary resections for cancer. Plastic and Reconstructive Surgery, 56, 171. Figures 23,24,26 and 29 are republished with the Editor’s permission from Bakamjian, V. Y. and Baldwin, M.: Major flaps in head and neck surgery, in “Proceedings of an International Symposium on Cancer of the Head and Neck”, Montreux, Switzerland, April 2-4, I975, pp. 287. Excerpta Medica International Congress, Series No. 365.
Figures36,38and 42 are republished with the Editor’s permission from Bakamjian, V. Y., Cervino, L., Miller, S. and Hentz, V. R.: The concept of cure and palliation by surgery in advanced cancer of the head and neck. American Journal of Surgery, 126, 482, 1973.
MAXILLO-FACIAL
AND PALATAL RECONSTRUCTIONS DELTOPECTORAL FLAP
By V. Y. BAKAMJIAN, M.D. and MICHAELPOOLE, F.R.C.S., Department of Head and Neck Surgey, Roswell Park Memorial New York 14.263, USA
WITH
THE
F.R.A.C.S.l
Institute, 666 Elm Street, Buffalo,
It is generally agreed that successful treatment of cancer involving the maxillary antrum usually requires surgical excision, whether alone or in combination with radiation therapy. Because cancer can remain occult for a long time in the bony confines of the region and not become evident until well advanced, such surgery is often radical. It may create a widely open defect with awesome proportions which may extend from the mouth to the dura vertically and from in front of the ear to the midline or further horizontally. If one is to have the courage to attempt the necessary resection, and if the unfortunate patient is to be willing to submit to the proposed treatment, prompt measures for dependable reconstruction are imperative for countering the dire implications of facial mutilation and oral dysfunction to the best possible degree. Formerly, a technique described by one of us (Bakamjian, 1963) for palatal restoration after radical maxillectomy was used extensively at the Roswell Park Memorial Institute in instances where the extent of the loss of supporting structures made impractical a satisfactory obturationof the palatal defect withaprosthesis. The methodused a lengthened modification of Owens’ (1955) compound flap of cervical skin and sternocleidomastoid muscle, including the muscle solely for the purpose of assuring viability without a preliminary delay. Valid and dependable in terms of the reconstruction, the
FIG. I. Case I. A and B, This women of 6g years sought relief from excruciating pain from this cancerous and radionecrotic lesion which had extensively destroyed tissues on the left face, nose, supra-orbital region and the eye, and had skeletonised the orbit and maxilla. Biopsy disclosed basal cell carcinoma, as well as some elements of squamous cell cancer in the inferior and lateral parts of the lesion. 1 Present England.
30/1-B
address: Middlesbrough
General Hospital,
I7
Ayresome
Lane,
Middlesbrough,
Cleveland,
18
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FIG. 2. Case I. A, After initial clearing by Mohs’ chemosurgery technique, limited to the margin area that was threatening the safety of the remaining eye, a radical resection was performed. This did not encompass the chemosurgically cleared portions at the glabellar and nasal areas. leavine them for excision at a later time, and it did not have to include the roof of the mouth. The temporalis muscle was dissected free from its origin on the squamous portion of the temporal bone and (B) rotated to cover exposed dura and irregular bony surfaces in the upper half of the defect. FIG. 3. Case I. A split-thickness skin graft covered the muscle flap and a deltopectoral flap (without delay) was used to cover the remainder of the defect.
FIG.4. Case I. After healing and I delay procedure on the base of the deltopectoral flap, the chemosurgically treated nasal and glabellar areas were also resected with exenteration of the tumour containing frontal sinus walls, and the flap base was transferred to cover the defect.
MAXILLO-FACIAL
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FIG. 5. Case I. A and B, In 2 final revisions the flap was divided at its middle and smoothed out on the face, leaving a fistula near the nasal region which could provide support for a facial prosthesis. Such a prosthesis was to be constructed, but relieved of her pain and satisfied with the result, the patient returned to her home town in the state of Maine and never returned for follow-up.
Fig. 6. Case 2. This man of 62 years came with an aggressive squamous cell cancer persisting after treatment which had completely destroyed his nose. He had had 12 operations and 4 courses of radiation treatment all to no avail. Already invading in the medial portions of the right orbit and maxilla, the cancer was also threatening to enter the left orbit. FIG. 7. Case 2. After exploring chemosurgically by Mohs’ technique the medial canthal It included remnants tain the safety of the left eye, a radical resection was performed. nasal septum, ethmoids and cribriform plate bilaterally, in addition to the right frontal maxilla, but the roof of the mouth was intact. Dura over an area of 6 x 6 cm was exposed roof of the defect.
region to ascerof the nose, the sinus, orbit and medially in the
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technique was open to criticism necessary later; nor is the flap applicable in of fixed or even nodal metastases in the neck. This pictorially presented report on a series of 7 maxillofacial resection cases illustrates approach, not subject to the same criticism, using in some differing
the
FIG. 8. Case 2. A and B, An extra long undelayed deltopectoral flap with a large deltoid paddle was used to cover the exposed dura and other raw surfaces in the wound. Unfortunately, however, a faint cyanosis in the deltoid portion began to proceed after 24 hours to a purple mottling and eventually to mummification by necrosis.
FIG. g. Case 2. Debridement was performed after I week and the granulating wound was grafted successfully with split-thickness skin after another week. At last report, 24 years after the resection, no tumour recurrence had occurred locally, but a shadow on chest X-ray was suggestive of either a metastasis or another primary in the lung.
MAXILLO-FACIAL
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FIG. IO. Case 3. A and B, This young man of rg years had a massive tmnour expanding the right maxillary antrum which had obliterated the right eye, filled rhe right nasal chamber with a fleshy mass, and The histology was that of an osteogenic sarcoma. bulged via the palate into the roof of the mouth.
FIG.
II. Case 3. Right orbito-maxillary resection included skin of the right cheek, anterior wall of the frontal sinus, the ethmoidal labyrinth, and a little more than the right half of the hard palate.
FIG. IZ.
Case 3.
A long large right deltopectoral
flap was raised without preliminary
delaying.
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FI G. 13. Case 3. A and B, The flap was tunnelled subcutaneously through an upper neck incision, passing on the outer side of the mandible, to close the palatal defect, epithelial side facing orally and raw side facing uFIward. Within the tunnel the flap was tubed in inverse manner to avoid opposing skin to the raw surfaces in the passage, and outside the tunnel it was tubed in the opposite direction, epithelium facing outward. A split-thickness skin graft was then applied to the upward-looking raw surface of the part forming the new roof of the mouth. FIG. 14.
Case 3.
A and B, Excepting a minor suture line separation between flap and mucoperiosteal edge of the palate, complete healing was achieved.
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FIG. 15. Case 3. After I delay procedure, the tubed segment of the flap was transposed on to the nasal septum, after removing its secretory mucous membrane. One month later, because of a positive biopsy from the fronto-ethmoidal region, 5,000 r radiation therapy was given over 30 days with good response. FIG. 16. Case 3. Two months after the fnst operation the tube of the pedicle was divided at its middle, the tunnelled portion was excised to close the fistula, and the remainder was applied to cover more of the posterior wall of the facial defect. Unfortunately about 6 months after this he succumbed to recurrent disease at the base of the skull, metastases, and a solid core of tumour growing down the right jugular vein into the heart. Death was attributed to right heart failure from extensive embolisation into the pulmonary arteries.
FIG. 17. Case 4. A and B, A 6o-year-old woman with an advanced maxillary cancer surfacing at the infraorbital and medial canthal region of the right eye and bulging with ulceration into the roof of the mouth.
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20 FIG. 18. Case 4. Radical orbito-maxillary resection included also the skin of the cheek and the masticatory muscles which had been infiltrated grossly with the tumour in the pterygoid fossa. FIG. 19. Case 4. As in case 3, a right undelayed deltopectoral flap was introduced by subcutaneous tunnelling and bi-directional tubing into the defect, but instead of forming the palate it was used as protective lining for exposed dura and raw surfaces in the defect. Radiotherapy followed after I week in view of the gross infiltration with tumour of the removed muscles and it was carried to a dose of 5,000 r in a period of S weeks. FIG. 20.
Case 4.
With
the flap healed and radiotherapy completed, secondary closure.
the palatal defect
remained
for
FIG. 21. Case 4. The tubed pedicle was divided at its base and the tunnelled segment was dissected free. By pulling it into the mouth and folding the pedicle on itself, the palate was reconstituted. Joining together the limbs of the folded tube in a subsequent stage completed the palatal closure, and a right-neck dissection was performed at the same time because a small mass had appeared in the submandibular area. This proved to be tumour in soft tissue around the submandibular salivary gland but none of the 34 lymph nodes examined were found to contain cancer.
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Case 4. She can now eat by mouth and speaks understandably with some degree of nasality. Close to 2 years after the resection, a small but deep recurrence has become evident behind and on the inner side of the mandibular angle on the right side.
FIG. 22.
FIG. 23. Case 5. A and B, This women of 56 years came with an excisional defect of the upper lip and the left orbito-maxillary region that contained recurrent adenoid-cystic carcinoma on all walls of the defect and a large nodule at the base of the right ala nasi. She gave a history of 5 resections and 2 courses of radiation therapy in over IO years, and most recently some chemotherapy and immunotherapy, all to no avail. Bilaterally, enlarged nodes were evident in the upper neck, and radiotomograrns showed lytic changes in the ethmoids and in the greater wing of the sphenoid bone. She was desperate for any treatment that could alleviate her obvious sufferings.
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FIG. 24. Case 5. A monobloc resection, mainly with intent to palliate, was attempted, knowing full well that cure was beyond any reasonable likelihood. It removed the nose, bilaterally the ethmoids and cribriform plate, the nasal septum, remnants from the previous orbito-maxillary resection on the left side, the medial half of the right maxtlla, and all of the palate excepting a short alveolar segment on the right side with z molar teeth. Torn in 2 places, the exposed dura was closed by suture.
FIG. 25.
Case 5. A and B, The left temporal muscle, released from its origin, was tunnelled subcutaneously into the defect and used to cover and buttress the repaired dura.
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Case 5. A, B and C, A large paddled and long deltopectoral flap was raised without preliminary delay. Tunnelled subcutaneously with bidirectional tubing as in the previous cases, the flap was used to line all parts of the excisional defect.
FIG.
28
FIG.
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FIG. 28.
Case 5.
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Healing was complete after recovery from a bout of meningitis antibiotics administered intrathecally.
which responded
to
Case 5, Divided from the chest, freed, from the subcutaneous tunnel and delivered into the facial defect, the tubed segment was used to restore palate and upper lip.
FIG. 29. Case 5. A and B, After a right neck dissection, modified by not removing the internal jugular vein and stemomastoid muscle, and a left supra-omohyoid neck dissection, a couple of minor revisions improved her appearance and her oral function. A skin-lined fistula from the nasal region to the centre of the rather flaccid palatal reconstruction was created for the purpose of wearing a prosthesis made of z components: a nasal component, and a tooth-bearing palatal component which could be snapped together with a connecting rod passed through the fistula. The patient however, pleased with the results from She has passable speech and eats by mouth. surgery, chose not to bother wearing the prosthesis. A shadow on X-ray in her right lung field has shown some growth on last report about I& years after the resection, but she remains asymptomatic and well palliated.
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FIG. 30. Case 6. This man of 6g years complained of pain in a huge mass of recurrent melanoma in and on the right maxilla which had obliterated the right eye, blocked the right nasal chamber, infiltrated into the right half of the upper lip, and perforated through the palate into the roof of the mouth. He gave a history of 4 resections and an intra-arterially administered course of chemotherapy without benefit shortly before coming to the Roswell Park Memorial Institute. FIG. 31. Case 6. Without any hope for cure, a proposal for palliative orbito-maxillary resection, including upper lip, skin of the cheek, parotid gland and ascending ramus of the mandible, was readily accepted by the patient. Tumour was encountered penetrating via the inferior orbital fissure and optic foramen into the cranial cavity.
FIG. 32.
Case 6. With merely a skin graft to cover raw parts, the defect was left open, making no elaborate initial attempt to reconstruct.
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Case 6. A and B, A right deltopectoral flap was delayed, folding at a right angle an extension of skin from the upper arm under the deltoid portion, thus providing the 2 layers necessary for the intended reconstruction.
FIG. 33.
FIG. 34.
Case 6. A and I$ Thus prepared the folded flap was moved into the facial defect to reconstitute the palate and missing half of the upper lip and restore his ability to eat and to speak.
31
FIG. 35. Case 6. A and B, Approximately 2 months after another stage to supplement the reconstruction by moving the tubed base of the flap into the facial defect, the patient began showing signs of intracranial involvement, gradually progressed into semicoma, and succumbed to terminal bronchopneumonia I year and 2 months after the major resection. FIG. 36. Case 7. This patient of 56 years had a poorly differentiated carcinoma of the right maxillary antrum in an advanced stage, persisting after a radiotherapy course of 6,000 r, and infected and draining pus after an attempted resection had been abandoned because the surgeon, in reflecting the cheek flap for exposure, had encountered tumour outside the bony confines of the antrum and had judged it to be non-resectable. FIG. 37. Case 7. At Roswell Park Memorial Institute, while receiving a course of chemotherapy with Bleomycin, a right deltopectoral flap was delayed with an extension of skin from the upper arm folded under the deltoid portion, as in the previous case.
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FIG. 38. Case 7. A and B, Radical orbito-maxillary resection including the skin of the cheek, the ethmoid labyrinth, pterygoid laminae and muscles, and the anterior half of the ascending ramus of the mandible.
FIG. 39. Case 7. For the immediate first step of reconstruction the prepared flap was moved into the defect, setting the single layer of its distal-most end against the nasal septum such that the doubled portion formed the roof of the mouth. FIG. 40.
Case 7.
Four weeks later the base of the well-healed flap was divided and implanted superiorly into the defect.
postero-
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Case 7. A and B, After another 4 weeks the now U-shaped flap was divided at its middle and its tubed posterior limb was opened upwards. C and D, The upper layer of its anterior limb was rolled backwards, forming a skin-lined tube from the region of the nasal root to the nasopharnyx, and the opened posterior limb was then brought down to close the cheek.
3011-c
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FIG. $2. Case 7. A and B,.The fistula at the side of the nasal root was purposely left open for toilet with irrigations to keep the &m-lined facial cavity clean, and also as anchorage for an ocular prosthesis. FIG. 43.
Case 7.
With the palate well restored, the patient is able to eat and speak normally and has remained free of cancer for more than 5 years since the resection.
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even in some situations appearing utterly hopeless, with radical surgery and expeditious reconstruction the surgeon and patient may be pleasantly surprised by an unexpected cure (as in case 7). Many a time, moreover, even if the hoped for cure proves impossible to obtain, palliation worth the effort is achieved with this approach, either obtaining a long-term control of local disease (as in case 5), or by ridding the patient of pain in a fast-expanding turnour mass (as in cases 3 and 6), or by eliminating an ulcerated, painful, easily bleeding, fungating and malodorous lesion (as in cases I and 5). In some there may even result improvements in function and appearance, albeit only for the patient’s limited remaining life. Concerning rehabilitation by prostheses it has been said that the efficiency is inversely proportional to the size of the defect the appliance closes (Longacre and Gilby, 1954). In radical maxillary resections with orbital exenteration and cheek resection such as those presented, the defect is indeed large and not well amenable to rehabilitation with a prosthesis. Active movements of the lower jaw and the extent of loss of teeth and other supporting structures in the upper jaw and face make the satisfactory fitting and wearing of a prosthesis, even to obturate the palatal defect, a major problem. The patients, moreover, usually find such a prosthesis, that requires frequent removal and cleaning, to be more of a nuisance than a help. The requirements of full surgical rehabilitation after a radical orbito-maxillary resection are threefold; immediate provision of adequate protective covering for raw wounds, bared bone and exposed dura or brain, closure of the palatal defect for oral function, and some form of masking and contour filling for the hollow orbito-facial defect to make the final appearance inoffensive. Most previous methods of repair tend to leave one or more of these requirements relatively not satisfied. Split skin grafts are commonly used to line the orbito-facial defect. Their relative inadequacy in protecting bare bone, dura or brain, their inability to close the palatal defect, or fill the facial contour, are self-evident. Flaps can serve better and temporal scalp flaps (Campbell, 1954) and forehead flaps (Stark, 1962; Thompson, 1970) have been used, but these procedures often result in unsightly scarring of the forehead. Alternatively, any exposed orbital bone and dura can be adequately protected and the orbital hollow can be filled with the temporalis muscle used as a flap (Naquin, 1956; Webster, 1957; Reese, 1958; Bakamjian and Souther, 1975). The muscle flap in turn can be covered with local eyelid skin, when this is available, or with a split skin graft (as in the case I) or with another flap (as in case 5). Reconstruction of the palatal loss after maxillectomy was probably first described by Foederl in 1903, although there are earlier reports of repair of other palatal defects using a forehead flap in 1869 and cheek tissues in 1867 (Longacre and Gilby, 1954). Foederl used an inferiorly based flap of nasal septum. Since than many methods of surgical palate repair have been described, including tubed skin pedicles (Padgett, 1936; Kostrubala, 1950; Edgerton and Zovickian, rg56), septal flap (Edgerton and Devito, 1963), Owens’ compound cervical flap (Bakamjian, rg63), and even a free jejunal transfer by vascular anastomosis (Black et al., 1971). A more or less comprehensive satisfaction of all 3 of the above mentioned reconstructive requirements is possible with the deltopectoral flap in a flexible variety of ways
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as is well demonstrated, particularly in cases 5 and 7; in addition to protective covering and palate closure, the large bulk of subcutaneous tissue and skin available with the deltopectoral flap allowed satisfactory contour filling for reconstruction of the orbitofacial defect as well. In other cases a fairly acceptable cheek defect was left, which could either adequately support wearing an external prosthesis (as in cases I and 3) or could be additionally repaired surgically with another flap. The question arises as to whether the flap is to be delayed before it is transferred. In the last 2 of this series it was-delayed for the purpose of giving a dual skin surface to its deltoid end by underfolding an extension at a right angle to it from the skin of the upper arm. In both instances the flap was successful. In the remaining 5 cases in which a delay was not used I extra large flap in a male patient failed (case 2), but flaps with comparable dimensions succeeded in 3 elderly females (cases I, 4 and 5), and also in I young male (case 3). This may be taken to suggest that when extended to beyond average dimensions the flap may prove relatively more reliable in female patients than in males, particularly in women who have lactated, because of a better developed internal mammary system of blood vessels. Finally, other variations in the manner of using the flap may be noted. In cases I, 2, 6 and 7 the first move of the flap was made directly into the opening of the orbitofacial defect by an external route, with tubing of the bridge segment. This provided protective covering in case I but failed to do so in case 2, and it restored the palate first in cases 6 and 7 with its previously folded end. In the remaining 3 cases the flap entered to its destination via a subcutaneous tunnel in the upper neck with the bridge segment tubed, skin-in within the tunnel and skin-out in its external course. In case 3 the flap went initially to restore the palate and its pedicle was subsequently moved into the Conversely, in cases 4 and 5 the orbitofacial defect to supplement the reconstruction. flap went initially to line the orbitofacial defect and its pedicle was subsequently used for restoration of the palate.
SUMhlARY
A flexible method for reconstruction of the defects resulting from radical orbitomaxillary resections is described with 7 illustrative case reports, using the deltopectoral flap.
REFERENCES
BAKAMJIAN,V. Y. (1963). A technique for primary reconstruction of the palate after radical maxillectomy for cancer. Plastic and Reconstructive Surgery, 31, 103. BAKAMJIAN,V. Y. and SOLJTHER, S. G. (1975). Use of temporal muscle flap for reconstruction after orbito-maxillary resections for cancer. Plastic and Reconstructive Surgery, 56, 171. BLACK,P., GRISWALD,B. A. and ARNOLD,P. G. (1971). One-stage palate reconstruction with a free neo-vascularized jejunal graft. Plastic and Reconstructive Surgery, 47, 316. CAMPBELL,H. H. (1954). Surgery of lesions of the upper face. American Journal of Surgery,
87, 676.
EDGERTON,M. T. and DEVITO, R. V. (1963). Closure of palate defects by means of a hinged nasal septum flap. Plastic and Reconstructive Surgery, 31, 537. EDGERTON,M. T. and ZOVICXIAN,A. (1956). Reconstruction of major defects of the palate. Plastic and Reconstructive Surgery, 17, 105. FOEDERL,0. (1903). Ueber gaumenplastik aus der nasenscheidewand. KOSTRUBALA, J. G. (1950). Repair of extensive palatal defects with skin tubes. Plustic and Reconstructive Surgery,
5, 512.
LONGACRE,J. J. and GILBY, R. F. (1954). The problem of reconstruction of extensive severely scarred palatal defects in edentulous patients. Plastic and Reconstructive Surgery,
14, 357.
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NAQUIN, H. (1956). Orbital reconstruction utilizing temporalis muscle. American Journal of Ophthalmology, 41, 519. OWENS, N. (1955). Compound neck pedicle designed for the repair of massive facial defects. Plastic and Reconstructive Surgery,
IS, 369.
PADGETT,E. (1936). The repair of cleft palate primarily unsuccessfully operated upon. Surgery, Gynecology and Obstetrics, 63, 483. REESE, A. B. (1958). Exenteration of the orbit: with transplantation of the temporalis muscle. American Journal of Ophthalmology, 45, 386. STARK,R. (1962). “Plastic Surgery”, p. 235. New York: Harper and Row. THOMPSON, H. (1970). Reconstruction of the orbit after radical exenteration. Plustic and Reconstructive Surgery, 45, I t9. WEBSTER,J. P. (1957). Temporalis muscle transplants for defects following orbital exenteration. “Transactions of the First International Congress on Plastic and Reconstructive Surgery”, p. 291. Baltimore: Williams and Wilkins Company. Figures I, 2,3 and 5 are republished with the Editor’s permission from Bakamjian, V. Y. and Souther, S. G.: Use of temporal muscle frap for reconstruction after orbito-maxillary resections for cancer. Plastic and Reconstructive Surgery, 56, 171. Figures 23,24,26 and 29 are republished with the Editor’s permission from Bakamjian, V. Y. and Baldwin, M.: Major flaps in head and neck surgery, in “Proceedings of an International Symposium on Cancer of the Head and Neck”, Montreux, Switzerland, April 2-4, I975, pp. 287. Excerpta Medica International Congress, Series No. 365.
Figures36,38and 42 are republished with the Editor’s permission from Bakamjian, V. Y., Cervino, L., Miller, S. and Hentz, V. R.: The concept of cure and palliation by surgery in advanced cancer of the head and neck. American Journal of Surgery, 126, 482, 1973.
