Reconstrucción de defectos palatinos con el colgajo de músculo buccinador / Reconstruction of palatal defects with the buccinator muscle flap"œ55

Los defectos palatinos de un tamaño significativo precisan reconstrucciones con colgajos locales o a distancia para evitar secuelas funcionalesimportantes, como regurgitación oronasal y rinolalia.El colgajo de músculo buccinador, descrito por Bozola en 1989 para el cierre de fístulas palatinas y reconstrucciones del paladar blando y duro, suponeuna interesante alternativa terapéutica en este tipo de defectos. En este trabajo presentamos una descripción anatómico-clínica y de la técnica quirúrgica del colgajo miomucoso de buccinador, así como nuestra pequeña casuística de pacientes operados en el Hospital Gregorio Marañón desde el año 2000 al 2004. De un total de 12 pacientes con defectos palatinos que fueron reconstruidos utilizando este colgajo, 4 eran hombresy 8 mujeres. La localización del defecto fue en 5 casos en el paladar duro y en 7 en paladar blando. Se realizaron reconstrucciones primarias tras resecciones oncológicas en 10 casos, mientras que 1 caso ha sido unareconstrucción secundaria tras fracaso de un colgajo temporal y, en otro paciente se utilizó para cubrir un injerto óseo preprotésico. Los resultados estéticos y funcionales fueron excelentes en 10 de los 12 casos.La complicación más frecuente fue la dehiscencia de sutura que se presentó en 5 casos, 3 de los cuáles fueron dehiscencias parciales que se resolvieronespontáneamente y, en los otros 2 casos, se precisó una reintervención. El colgajo de músculo buccinador parece una interesante técnica reconstructiva para defectos palatinos. Constituye un método quirúrgico sencillo,poco agresivo, con mínimas secuelas y buenos resultados. También puede ser empleado para resolver defectos de labio, lengua, mucosa yugal y órbitas, así como en casos de insuficiencia velopalatina

Defects of the palate that are of a significant sizerequire reconstruction with local or distant flaps in order to avoid important functional sequelae such as oronasal regurgitation and rhinolalia. The buccinator muscle flap, described by Bozola in 1989 for closing palatal fistulas and for reconstruction of the soft and hard palate, represents an important therapeuticalternative for this type of defect. In this work we present an anatomic-clinical description and the surgical technique with the myomucosal flap ofbuccinator muscle, as well as a small series of patientsoperated on in the Gregorio Marañon Hospital from theyear 2000 to the year 2004. Of a total of 12 patientswith palatal defects that were reconstructed using thisflap, 4 were men and 8 were women. The defects in 5cases were located in the hard palate and 7 were locatedin the soft palate. Primary reconstruction was carriedout following oncological resectioning in 10 cases,while in 1 case secondary reconstruction was carried outafter failure with a temporalis muscle flap, and in another patient it was used to cover a preprosthetic bone graft. The aesthetic and functional results were excellent in 10 out of 12 cases. The most common complication was dehiscence of the suture which occurred in five cases, three of which were resolved spontaneously and in another two cases it was necessary to re-operate. The buccinator muscle strikes us an interesting reconstruction technique for defects of the palate. It represents a surgical method that is simple and hardly aggressive, with very few sequelae and good results. It can also be used for resolving defects of the lip, tongue, jugal mucosa and of the orbits, as well as for cases of velopalatal insufficiency

Colgajo miomucoso de buccinador en la reconstrucción de defectos del área maxilofacial / The buccinator myomucosal flap for the reconstruction of defects in the maxillofacial area

El colgajo miomucoso de buccinador (CMB) constituye una alternativa válida para la reconstrucción de defectos intraorales de tamaño moderado. Se caracteriza por su buena plegabilidad, excelente color y textura,además de una mínima morbilidad de la zona donante.En el presente trabajo se describen las particularidades anatómicas de dicho colgajo, así como las diferentes técnicas quirúrgicas que pueden emplearsepara su obtención. Su utilización en diferentes defectos de la cavidad oral, ilustra la versatilidad del mismo. Presentamos 4 casos de reconstrucciónde defectos del área maxilofacial: dos pacientes con carcinoma epidermoide de suelo de boca, un paciente con melanoma de mucosa y un paciente con fisura palatina. Se obtuvieron resultados óptimos en cuanto a cobertura del defecto postquirúrgico, estética y función. En todos loscasos la morbilidad de la zona donante fue mínima. Dadas sus particularidades anatómicas, debe realizarse una cuidadosa técnica de obtención del mismo. La proximidad del CMB a la gran mayoría de los defectos de lacavidad oral y su aceptable espesor, hace del mismo una opción reconstructiva eficaz, sobre todo en aquellos pacientes en los que el tamaño del defecto y/o la existencia de patología asociada desaconsejan el uso de otros colgajos

The buccinator myomucosal flap (BMF) constitutesa valid alternative for the reconstruction of moderate defects of the oral cavity. It is characterized by a good pliability, excellent color and texture and minimum donor site morbidity. In this report, the anatomical particularities and the different surgical techniques for BMF are described. Its use in patients with different defects of the oral cavity illustrates its versatility. We present 4 cases of reconstruction of defects of the maxillofacial area: two cases consisting in squamous cell carcinoma of the floor of the mouth, another patient with melanoma of the oral mucosa and one patient with a palatine fissure. All of them underwent primary reconstruction by means of BMF. Good results were obtained in relation to covering of the defect, aesthetics and function. Morbidity was minimal in the donor site. Due to its anatomical features,an adequate surgical technique must be performed. Proximity of the BMF to the vast majority of defects of the oral cavity, and its acceptable thickness, show the flap to be a reliable reconstructive procedure. This is especially valid in those patients where the size of the defect and the existence of comorbidity advise against the use of other flaps (AU)

[Submucous implantation with pedicel auto-flap of cheek muscle for atrophic rhinitis].

This paper described a method of submucous implantation for 32 patients with atrophic rhinitis by using pedicel auto-flap of cheek muscle and maxillary periosteum of piriform aperture. The results indicated that the total effective rate was 100% and the evident effective rate was 90.6% after 1 to 3 year postoperatively. The cilia beat of nasal mucosa, blood flow, osmotaxis of blood vessel. P substance and the resistance of nasal airflow were all improved. The flap survived and grew well due to autogenuous graft tissues and its original blood supply. No complications have been found. The clinical efficiency was obvious for a short term and was stable for a long term.

[Closing of central palate defects using a temporal muscle flap]. / Het sluiten van centrale palatumdefecten met de musculus temporalis-lap.

Large defects of the maxilla are hard to repair. In spite of the prosthesis that covers the defect, patients complain of loss of fluid through the nose when they drink or take liquid food. In five patients the maxillary defect was successfully closed by transposing the anterior part of the temporal muscle or the entire temporal muscle. The donor site was covered by transposing the posterior part of the temporal muscle or by an implant.

[Experimental validation of the use of the masseter muscle in treating paralysis of the mimetic muscles]. / Eksperimental'noe obosnovanie ispol'zovaniia zhevatel'noi myshtsy pri lechenii paralichei mimicheskikh myshts.

In 15 rabbits the distal end of masseter muscle was surgically transposed to perioral region. After 90, 120 and 180 days the altered muscle position and reduction of functional load did not cause its degeneration. Rather, these conditions elicited a functional reordering evidenced by reduction of muscular fibers' cross-sectional area, the number of surrounding capillaries, decrease in the succinate dehydrogenase activity and increase in connective tissue layer.

The masseter muscle cross-over flap--a versatile flap for reconstruction in the oral cavity.

The use of the masseter muscle cross-over flap is described for reconstruction in the floor of mouth, retromolar trigone, lateral pharyngeal wall and posterior palate areas. Various modifications are described which increase the versatility of this readily available flap. Case reports are used to illustrate the applications of this flap.

Role of masseter crossover flap in oropharyngeal reconstruction.

Oropharyngeal reconstruction especially after surgery for medially located lesions of moderate dimensions presents a challenge. The risk of using well vascularized, but insensitive tissues close to the airway has led to the development of several measures to overcome the difficulties involved. The transposition of masseter muscle which has been put forward in recent years provides successfully primary closure with preservation of function.

The fasciaform graft: a technique for the repair of large perforations of the tympanic membrane.

Our experience with the fasciaform graft, designed specifically for the repair of subtotal or total perforations of the tympanic membrane, is presented. The technique which utilizes a total tympanic graft of formalized autologous temporalis fascia is described in detail. We have employed this method in 29 patients with total closure of the defect being achieved in 93% of cases. The fasciaform graft is therefore recommended as a successful method of repair for subtotal and total perforations of the tympanic membrane for which the conventional grafting techniques currently available are much less effective.

The temporalis muscle flap for intraoral reconstruction: technical modifications.

For three years we have used the temporalis muscle flap for reconstruction of intraoral defects. Advantages of this flap are that it is non-hair-bearing, nonbulky, pliable, durable, proximal to intraoral defects, and it results in better articulation and deglutition. We have modified our original technique so that we facilitate transference of the flap by a more anterior transection through the zygomatic arch, we improve the aesthetic reconstruction by use of the transected coronoid process, we produce better function by preventing adhesions and granulation tissue, and we enhance definition of the lingual sulcus by splinting.

Versatility of temporal muscle and fascial flaps.

The muscle and superficial fascia of the temporal area differ in their physical characteristics, vascular supply and clinical applications. Both can be employed independently or simultaneously as regional flaps in the reconstruction of a variety of complex craniofacial defects. The present paper reviews the anatomy, surgical technique and utilisation of temporal flaps.

Surgery on the buccal fat pad in masseter transfer.

The buccal fat pad is an essential anatomic structure in the esthetic presentation of the face. It may become hypertrophied, with fullness of the cheek, or atrophic, with a sunken appearance, or become a plus or minus factor in reconstruction in this area. Lipoma of this pad is extremely rare, but it must also be differentiated. There are, therefore, certain circumstances where the presence or absence of the buccal fat pad can create a specific imbalance and asymmetry in the face. The correction of these conditions may require reduction or augmentation. The anatomy, the risks, the classification, and the various surgical techniques that are available to accomplish this are outlined and correlated to the masseter muscle transfer.

[The temporal muscle flap. Its use in transmaxillary oro-pharyngectomy]. / Le lambeau du muscle temporal. Son utilisation dans les buccopharyngectomies transmaxillaires.

Results are reported of the use of four temporal muscle flaps for reconstruction of the floor of mouth and the velo-amygdalo-palatine region after transmaxillary buccopharyngectomy for malignant tumor. The good vascularization of the temporal flap ensured very satisfactory immediate and long term results.

The temporalis muscle flap for intraoral reconstruction.

In this series of seven patients, we used the temporalis muscle flap for reconstruction of tongue and floor-of-mouth defects. For intraoral reconstruction, the temporalis muscle flap has advantages over the standard workhorse flap, the pectoralis major. The temporalis muscle flap is far less bulky, more pliable, non-hair bearing, and in closer proximity to the oral cavity. Use of this muscle does not impair mandibular function. The depression that results after the temporalis muscle has been transferred is minimal. Most of this donor area is covered by hair. The only site where the depression can be significant is at the zygomatic arch, where the tunnel into the mouth is formed after removal of the arch. If the arch is wired back into position, this aesthetic detriment is obviated. In gaining exposure of the zygomatic arch, significant traction can be placed on the soft tissues through which the temporal branch of the facial nerve runs. In one patient, a temporal nerve branch paralysis occurred that required a browpexy; in another patient, there was a transient paresis; and in the others, there was no deficit. The temporalis muscle flap is hardy and durable, and has become our mainstay flap for intraoral reconstruction.

Mandibular reconstruction by myo-osseous (temporalis muscle/outer table of skull) flap.

An operation for mandibular reconstruction using a vascularised bone graft from the outer table of the skull is described. Temporalis muscle as the pedicle provides the blood supply to the bone graft. Possible complications, advantages and disadvantages of the procedure are discussed.

[The temporal muscle flap and palatal repair]. / Lambeau de muscle temporal et réparation du palais.

Two edentulous elderly women presented with benign but extensive tumors of middle third of face. The excision necessary for reasons of comfort and hygiene could not be envisaged unless the ineluctable vast palatine breach opened could be immediately repaired by surgery, any prosthetic solution being excluded. The use of a total temporal muscle flap, without zygoma section, provided an effective and comfortable solution to this both delicate and unusual problem. These cases illustrate the interest in the use of temporal muscle flaps in maxillofacial surgery, and their management for the repair of large palatine breaches.