422
PHARYNGEAL
J Oral Maxillofac
FLAP, TEMPORAL MUSCLE FOR REPAIR OF CLEFT
Surg
1991
49:422-425.
Use of the Pharyngeal Flap With Temporalis Muscle for Reconstruction the Unrepaired Adult Palatal Cleft:
of
Report of Two Cases BURCIN F. TARTAN, DMD,* GEORGE C. SOTEREANOS, MS, DMD, FACD,t GARY T. PATTERSON, DMD,S AND MICHAEL J. GIULIANI, MD5
The unrepaired adult palatal cleft exists because the extensive nature of the defect makes surgical closure by use of local flaps and hard and soft palatal tissue difficult, if not impossible. In the past, this problem was resolved by the use of prosthetic obturators. Disadvantages of these obturators are the necessity for continual adjustments, oral hygiene, use for an overlay that may cause loss of natural dentition, bulkiness of the apparatus, and the psychological aspects associated with its use. Currently, these extensive defects can be successfully corrected surgically by use of the temporalis muscle.’ This article describes use of the superiorly based pharyngeal flap’ attached to the temporalis muscle for palatal repair and correction of the velopharyngeal insufficiency. Using this procedure, speech rehabilitation and closure of the extensive hard- and soft-palatal defect are accomplished. Report of Two Cases Case 1 A 65-year-old woman in good physical condition presented for correction of her unrepaired cleft palate. The defect anterior-posteriorly included the maxillary vestibule, anterior alveolus, and the entire hard and soft palate, which was a distance of approximately 7.5 cm (Figs Received from Presbyterian-University Hospital, Pittsburgh, PA. * Resident, Division of Oral-Maxillofacial Surgery. t Director of Graduate Training, Division of Oral-Maxillofacial Surgery. Z!Assistant Professor, Division of Oral-Maxillofacial Surgery. 8 Assistant Professor, Department of Neurology. Address correspondence and reprint requests to Dr Sotereanos: University of Pittsburgh, Division of Oral-Maxillofacial Surgery, 660 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261, 0 1991 American Association of Oral and Maxillofacial geons 0278-2391/91/4904-0019$3.00/0
Sur-
IA and B). The greatest distance separating the palatal shelves mediolaterally was 4.3 cm. Her maxillary dental units on the left side included the canine to the second molar, and on the right side the first premolar to the first molar. She wore a large obturator with a speech bulb that extended to the postpharyngeal wall. There was chronic mucosal irritation involving the soft tissue of the palatal shelves and leakage of fluids and air into the nasal fossa, especially in the anterior portion of the defect, in spite of constant maxillofacial prosthodontic adjustments. The lip was repaired in infancy. The anterior maxillary vestibule and the entire hard and soft palate. including the uvula, had been left unrepaired. Transmaxillary temporalis muscle transfer was effected for complete hard and soft palatal repair using a hemicoronal approach (Fig 1C and D). This procedure has been described previously by Demas and Sotereanos.’ A variation in this particular case was introduction of the temporalis muscle above the apices of the molar units on the right side to preserve their integrity. Postoperatively, evalulation of the velopharyngeal function by means of videoendoscopy showed a distance of approximately 15 mm between the posterior extent of the soft palate (temporalis muscle), and the posterior pharyngeal wall. The patient had hypemasality and nasal emission, which reflected velopharyngeal insufficiency. There was considerable activity in the superior constrictor on both the lateral and posterior walls. A modified obturator was used for speech function until the pharyngeal flap procedure could be accomplished. Sixteen months later, a superiorly based pharyngeal flap was developed and attached to the temporalis muscle at the most posterior aspect of the recreated soft palate. Case 2 A %-year-old woman presented for correction of an unrepaired cleft palate. The cleft included the premaxilla, which was absent, and extended posteriorly to include the hard and entire soft palate. The defect measured 6.0 cm anterior-posteriorly. The longest distance mediolaterally was 3.5 cm. The maxilla was edentulous (Fig 2A). She wore a large palatal pharyngeal speech obturator. A transmaxillary temporalis muscle transfer was accomplished for hard- and soft-palate reconstruction (Fig 2B). Her postoperative speech evaluation indicated improvement in articulating skills; however, hypemasality and
423
TARTANETAL
FIGURE 1. Preoperative and postoperative views of the palatal defect in patient 1. A, Preoperative anterior view. B, Preoperative posterior view. C, Postoperative anterior view. D, Postoperative posterior view.
nasal emission continued to exist because of velopharyngeal incompetency. Ten months later, a superiorly based pharyngeal flap was dissected and anastomosed to the repaired palate (temporalis muscle). RESULTS
Speech Six months postoperatively, the findings were similar in both cases. Speech evaluation indicated a preoperative to postoperative improvement in articulation and overall intelligibility. The improvement in articulation was primarily in the production of the lingual-alveolar affricative consonants [ts] and [dz] (/ch/ and /dz/ as in “church” and “‘judge”). Several articulation errors were present, including, in the first patient, a distorted Is/ and omission of the lingua-velar plosive consonants IW and/g/. These sound errors had been present preoperatively during conversational speech with the speech obturator in place. However, postoperatively, these articulatory errors were modifiable with practice. In the first patient, nasal grimacing and nasal snort, which had been present preoperatively, were not present postoperatively. In both patients, nasal emission and hypernasality were still evident in spite of improved articulation (Dr Quinter Berry, personal communication, January 1990). Anatomic Findings Follow-up magnetic resonance imaging (MRI) was done postoperatively to assess location, degenerative
changes, and the relationship of the two flaps. In the first patient, the studies were performed on the 12th and 15th postoperative months. Both studies showed an intact temporalis muscle flap without interval changes in configuration or in signal intensity to suggest degeneration. In the sagittal Tl-weighted image, the pharyngeal flap was seen to reflect from the posterior wall of the pharynx and anastomose with the posterior edge of the temporalis flap (Fig 3A). In the axial Tl-weighted image, small signal voids were seen at either side that represented the residual airway between the pharyngeal flap and the lateral wall of the pharynx, and indicated the patency of the lateral ports (Fig 3B). In the second patient, MRI was done 10 months and 3 years postoperatively. In these studies, the right temporalis muscle flap extending to the palate appeared intact, without suggestion of degeneration in the axial TIweighted image (Fig 4A). The findings with the pharyngeal flap were similar (Fig 4B). Electromyographic
Findings
Electromyographic (EMG) studies were performed on both patients postoperatively to assess the innervation of the temporalis muscle flaps. In both cases, the transpositioned temporalis muscle had normal electyromyographic activity as far as spontaneous activity and motor unit morphology. In the first case, the transpositioned segment of the right temporalis muscle displayed voluntary recruitment
PHARYNGEAL
424
FLAP, TEMPORAL MUSCLE FOR REPAIR OF CLEFT
muscle displayed recruitment of motor units during jaw opening and, to a lesser extent, with jaw closure, opposite to the expected pattern, which would suggest relearning. The nontranspositioned remaining one third of the temporalis muscle, which was anteriorly replaced in the temporalis fossa, showed normal electromyographic in both cases.
activity
Discussion
FIGURE 2.
Preoperative and postoperative views of patient 2. view. B, Postoperative view.
A, Preoperative
on jaw opening, closing, and functional use of the palate (swallowing and speaking). In the last situation, the level of firing was greater than with either opening or closing of the jaw. In the second patient, the transpositioned temporalis
Following treatment, both patients reported significant improvement in mastication, swallowing, breathing, and articulation. Further speech therapy is indicated, however, to correct articulatory patterns that had been habituated preoperatively and were modifiable postoperatively. Of interest in both cases is what occurred to the muscle activation pattern and function. Electromyographic studies in both cases showed viable temporalis muscle with normal motor nerve innervation. The ability to voluntarily fire these units, particularly in the functional use of the palate, indicated “reconditioning,” probably centrally, to allow this translocated muscle to contract functionally.3 This finding was similar to that of Itah and Sasaki4 in the transfer of latissimus dorsi to replace a paralyzed anterior deltoid, which reflected motor relearning. This would suggest that the central nervous system maintains some ability to adopt a new firing pattern after transposition of fully innervated muscle. Summary Use of a pharyngeal flap with the temporalis muscle has been shown in two cases to be an effective surgical means of correcting an existing velopharyngeal incompetency with satisfactory results in
FIGURE 3. Sagittal Tl-weighted MRI showing attachment of pharyngeal flap to soft palate (temporalis muscle). B, Axial Tl-weighted MRI showing patency of lateral ports (arrows).
425
TARTAN ET AL
FIGURE 4. Axial Tl-weighted between the two flaps.
MRI showing an intact temporalis muscle flap. B, Sagittal Tl-weighted
terms of both speech articulation tion.
and muscle func-
References 1. Demas P, Sotereanos GC: Transmaxillary temporalis transfer for reconstruction of a large palatal defect. .l Oral Maxillofac Surg 47: 197, 1989
MRI showing the anastomosis
2. Millard R: Velopharyngeal synechiae with various pharyngeal flaps, in Cleft Craft, ~013. Boston, MA, Little Brown & Co, 1980, p 605 (chapt 36) 3. Thompson RF, Berger TW, Madden J: Cellular process of leamina and memorv in the mammalian CNS. Annu Rev Neurosci 6447, 1983 4. Itah Y, Sasaki T: Transfer of lattismus dorsi to replace a paralyzed anterior deltoid. J Bone Joint Surg 69647, 1987
PHARYNGEAL
J Oral Maxillofac
FLAP, TEMPORAL MUSCLE FOR REPAIR OF CLEFT
Surg
1991
49:422-425.
Use of the Pharyngeal Flap With Temporalis Muscle for Reconstruction the Unrepaired Adult Palatal Cleft:
of
Report of Two Cases BURCIN F. TARTAN, DMD,* GEORGE C. SOTEREANOS, MS, DMD, FACD,t GARY T. PATTERSON, DMD,S AND MICHAEL J. GIULIANI, MD5
The unrepaired adult palatal cleft exists because the extensive nature of the defect makes surgical closure by use of local flaps and hard and soft palatal tissue difficult, if not impossible. In the past, this problem was resolved by the use of prosthetic obturators. Disadvantages of these obturators are the necessity for continual adjustments, oral hygiene, use for an overlay that may cause loss of natural dentition, bulkiness of the apparatus, and the psychological aspects associated with its use. Currently, these extensive defects can be successfully corrected surgically by use of the temporalis muscle.’ This article describes use of the superiorly based pharyngeal flap’ attached to the temporalis muscle for palatal repair and correction of the velopharyngeal insufficiency. Using this procedure, speech rehabilitation and closure of the extensive hard- and soft-palatal defect are accomplished. Report of Two Cases Case 1 A 65-year-old woman in good physical condition presented for correction of her unrepaired cleft palate. The defect anterior-posteriorly included the maxillary vestibule, anterior alveolus, and the entire hard and soft palate, which was a distance of approximately 7.5 cm (Figs Received from Presbyterian-University Hospital, Pittsburgh, PA. * Resident, Division of Oral-Maxillofacial Surgery. t Director of Graduate Training, Division of Oral-Maxillofacial Surgery. Z!Assistant Professor, Division of Oral-Maxillofacial Surgery. 8 Assistant Professor, Department of Neurology. Address correspondence and reprint requests to Dr Sotereanos: University of Pittsburgh, Division of Oral-Maxillofacial Surgery, 660 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261, 0 1991 American Association of Oral and Maxillofacial geons 0278-2391/91/4904-0019$3.00/0
Sur-
IA and B). The greatest distance separating the palatal shelves mediolaterally was 4.3 cm. Her maxillary dental units on the left side included the canine to the second molar, and on the right side the first premolar to the first molar. She wore a large obturator with a speech bulb that extended to the postpharyngeal wall. There was chronic mucosal irritation involving the soft tissue of the palatal shelves and leakage of fluids and air into the nasal fossa, especially in the anterior portion of the defect, in spite of constant maxillofacial prosthodontic adjustments. The lip was repaired in infancy. The anterior maxillary vestibule and the entire hard and soft palate. including the uvula, had been left unrepaired. Transmaxillary temporalis muscle transfer was effected for complete hard and soft palatal repair using a hemicoronal approach (Fig 1C and D). This procedure has been described previously by Demas and Sotereanos.’ A variation in this particular case was introduction of the temporalis muscle above the apices of the molar units on the right side to preserve their integrity. Postoperatively, evalulation of the velopharyngeal function by means of videoendoscopy showed a distance of approximately 15 mm between the posterior extent of the soft palate (temporalis muscle), and the posterior pharyngeal wall. The patient had hypemasality and nasal emission, which reflected velopharyngeal insufficiency. There was considerable activity in the superior constrictor on both the lateral and posterior walls. A modified obturator was used for speech function until the pharyngeal flap procedure could be accomplished. Sixteen months later, a superiorly based pharyngeal flap was developed and attached to the temporalis muscle at the most posterior aspect of the recreated soft palate. Case 2 A %-year-old woman presented for correction of an unrepaired cleft palate. The cleft included the premaxilla, which was absent, and extended posteriorly to include the hard and entire soft palate. The defect measured 6.0 cm anterior-posteriorly. The longest distance mediolaterally was 3.5 cm. The maxilla was edentulous (Fig 2A). She wore a large palatal pharyngeal speech obturator. A transmaxillary temporalis muscle transfer was accomplished for hard- and soft-palate reconstruction (Fig 2B). Her postoperative speech evaluation indicated improvement in articulating skills; however, hypemasality and
423
TARTANETAL
FIGURE 1. Preoperative and postoperative views of the palatal defect in patient 1. A, Preoperative anterior view. B, Preoperative posterior view. C, Postoperative anterior view. D, Postoperative posterior view.
nasal emission continued to exist because of velopharyngeal incompetency. Ten months later, a superiorly based pharyngeal flap was dissected and anastomosed to the repaired palate (temporalis muscle). RESULTS
Speech Six months postoperatively, the findings were similar in both cases. Speech evaluation indicated a preoperative to postoperative improvement in articulation and overall intelligibility. The improvement in articulation was primarily in the production of the lingual-alveolar affricative consonants [ts] and [dz] (/ch/ and /dz/ as in “church” and “‘judge”). Several articulation errors were present, including, in the first patient, a distorted Is/ and omission of the lingua-velar plosive consonants IW and/g/. These sound errors had been present preoperatively during conversational speech with the speech obturator in place. However, postoperatively, these articulatory errors were modifiable with practice. In the first patient, nasal grimacing and nasal snort, which had been present preoperatively, were not present postoperatively. In both patients, nasal emission and hypernasality were still evident in spite of improved articulation (Dr Quinter Berry, personal communication, January 1990). Anatomic Findings Follow-up magnetic resonance imaging (MRI) was done postoperatively to assess location, degenerative
changes, and the relationship of the two flaps. In the first patient, the studies were performed on the 12th and 15th postoperative months. Both studies showed an intact temporalis muscle flap without interval changes in configuration or in signal intensity to suggest degeneration. In the sagittal Tl-weighted image, the pharyngeal flap was seen to reflect from the posterior wall of the pharynx and anastomose with the posterior edge of the temporalis flap (Fig 3A). In the axial Tl-weighted image, small signal voids were seen at either side that represented the residual airway between the pharyngeal flap and the lateral wall of the pharynx, and indicated the patency of the lateral ports (Fig 3B). In the second patient, MRI was done 10 months and 3 years postoperatively. In these studies, the right temporalis muscle flap extending to the palate appeared intact, without suggestion of degeneration in the axial TIweighted image (Fig 4A). The findings with the pharyngeal flap were similar (Fig 4B). Electromyographic
Findings
Electromyographic (EMG) studies were performed on both patients postoperatively to assess the innervation of the temporalis muscle flaps. In both cases, the transpositioned temporalis muscle had normal electyromyographic activity as far as spontaneous activity and motor unit morphology. In the first case, the transpositioned segment of the right temporalis muscle displayed voluntary recruitment
PHARYNGEAL
424
FLAP, TEMPORAL MUSCLE FOR REPAIR OF CLEFT
muscle displayed recruitment of motor units during jaw opening and, to a lesser extent, with jaw closure, opposite to the expected pattern, which would suggest relearning. The nontranspositioned remaining one third of the temporalis muscle, which was anteriorly replaced in the temporalis fossa, showed normal electromyographic in both cases.
activity
Discussion
FIGURE 2.
Preoperative and postoperative views of patient 2. view. B, Postoperative view.
A, Preoperative
on jaw opening, closing, and functional use of the palate (swallowing and speaking). In the last situation, the level of firing was greater than with either opening or closing of the jaw. In the second patient, the transpositioned temporalis
Following treatment, both patients reported significant improvement in mastication, swallowing, breathing, and articulation. Further speech therapy is indicated, however, to correct articulatory patterns that had been habituated preoperatively and were modifiable postoperatively. Of interest in both cases is what occurred to the muscle activation pattern and function. Electromyographic studies in both cases showed viable temporalis muscle with normal motor nerve innervation. The ability to voluntarily fire these units, particularly in the functional use of the palate, indicated “reconditioning,” probably centrally, to allow this translocated muscle to contract functionally.3 This finding was similar to that of Itah and Sasaki4 in the transfer of latissimus dorsi to replace a paralyzed anterior deltoid, which reflected motor relearning. This would suggest that the central nervous system maintains some ability to adopt a new firing pattern after transposition of fully innervated muscle. Summary Use of a pharyngeal flap with the temporalis muscle has been shown in two cases to be an effective surgical means of correcting an existing velopharyngeal incompetency with satisfactory results in
FIGURE 3. Sagittal Tl-weighted MRI showing attachment of pharyngeal flap to soft palate (temporalis muscle). B, Axial Tl-weighted MRI showing patency of lateral ports (arrows).
425
TARTAN ET AL
FIGURE 4. Axial Tl-weighted between the two flaps.
MRI showing an intact temporalis muscle flap. B, Sagittal Tl-weighted
terms of both speech articulation tion.
and muscle func-
References 1. Demas P, Sotereanos GC: Transmaxillary temporalis transfer for reconstruction of a large palatal defect. .l Oral Maxillofac Surg 47: 197, 1989
MRI showing the anastomosis
2. Millard R: Velopharyngeal synechiae with various pharyngeal flaps, in Cleft Craft, ~013. Boston, MA, Little Brown & Co, 1980, p 605 (chapt 36) 3. Thompson RF, Berger TW, Madden J: Cellular process of leamina and memorv in the mammalian CNS. Annu Rev Neurosci 6447, 1983 4. Itah Y, Sasaki T: Transfer of lattismus dorsi to replace a paralyzed anterior deltoid. J Bone Joint Surg 69647, 1987
