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Use of Local and Axial Pattern Flaps for Reconstruction of the Hard and Soft Palate

Ramesh K. Sivacolundhu, BVMS, MVS, FACVSc


There are numerous conditions that may result in defects of the hard and soft palate. Reconstruction of these defects may be difcult due to anatomical limitations and limited tissue availability. The majority of palate defects, even when large, may be closed using local and/or axial pattern aps, while other more advanced techniques such as free tissue transfer and prosthetic implants are required in a smaller number of cases. This article describes the use of local and axial pattern aps in the reconstruction of the hard and soft palate. Clin Tech Small Anim Pract 22:61-69 2007 Elsevier Inc. All rights reserved. KEYWORDS palate, ap, defect, mucoperiosteal, transposition, axial pattern, angularis oris, dog, cat

efects in the hard and soft palate may result from congenital abnormalities, resection of neoplasms, traumatic injuries, severe peridontal disease, tooth removals, severe chronic infections, and, secondarily, to surgical and radiation therapy.1-5 Reconstruction of these defects can be challenging. The area concerned presents a number of anatomical limitations, with difculties in exposure and access to affected areas, and limited tissue available for reconstruction of defects. In addition, the repair must withstand mechanical stresses induced during mastication and deglutition.1 Reconstruction of palate defects requires a detailed knowledge of the local anatomy, and an understanding of the various options available to the surgeon. This may be particularly important in cases of large defects, or when radiation or previous surgeries have compromised local tissue.1 There are a number of general principles described by Harvey3 and Luskin4 that should be followed when considering surgery on a patient with a palate defect:

Suture tissues to freshly incised epithelium. A ap sutured to an intact epithelial surface will not heal. Incisions should be made with a scalpel blade rather than scissors to minimize crushing injuries. Avoid the use of electrosurgery or cauterization to control bleeding. Where possible, arrange suture lines so they are situated over connective tissue rather than over the defect, thereby preventing drying and contamination of the connective tissue side of the ap and decreasing the risk of dehiscence. Suture tissue gently and with large bites of tissue to minimize tension and interference with blood supply at the wound edges.

Make aps large compared with the size of the defect to minimize tension. Preserve the vascular supply to aps by elevating adequate underlying connective tissue. For hard palate epithelium, this means elevating the mucoperiosteum as one layer and avoiding the palatine artery, which penetrates the palatine bone approximately 1 cm medial to the carnassial tooth and then runs caudally and rostrally parallel to the midline.

The Animal Medical Center, New York, New York. Address reprint requests to Ramesh K. Sivacolundhu, BVMS, MVS, FACVSc, The Animal Medical Center, 510 East 62nd Street, New York, NY 100218314. E-mail: ram.siva@amcny.org

Suture materials used are usually 3/0, 4/0, or 5/0 absorbable suture material, depending on the size of the animal, type of repair being performed, and type of tissue being sutured (hard palate mucosa, soft palate mucosa, or buccal mucosa). This author generally prefers the use of polydioxanone, although other absorbable and nonabsorbable suture materials have also been utilized. If knots are left on the epithelial surface, they will usually slough in 3 to 4 weeks regardless of the type of suture material used.3 There are several reports of management of palate defects in dogs and cats, with a variety of techniques described. Techniques that have been used for reconstruction or management of palate defects include local aps,3,5-8 axial pattern aps,1,9 distant tissue with use of a rostral tongue ap,10 free tissue transfer with microvascular anastomosis,2 and prosthetic appliances.11-14 The aim of this article is to describe the use of local and axial pattern aps in the reconstruction of the hard and soft palate. 61

1096-2867/07/$-see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.ctsap.2007.03.005

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created by performing releasing incisions in the hard palate mucosa longitudinally along the length of the defect, adjacent and medial to the dental arcade.8 The ap has attachments maintained rostrally and caudally. Incisions are also made approximately 2 mm away from the edge of the midline defect. Elevation of the ap continues from medial to lateral, being careful to avoid the palatine artery. A simple hingedap is created by elevating the mucosa adjacent to the defect, continuous with the nasal mucosal, and hinging it across the defect. The ap is sutured primarily using simple interrupted sutures, thereby reconstructing the nasal mucosal defect. The bipedicled aps may then be mobilized to reconstruct the oral mucosa, again using simple interrupted sutures.19 It is unnecessary to repair the resulting lateral defects with exposed palatine bone since these defects will epithelialize rapidly.8,19 A bone free-graft from the medial tibia has been placed between the reconstructed oral and nasal mucosa to encourage bone formation,18 although this step appears to be unnecessary.19

Local Flaps for the Hard Palate


Numerous local aps have been used to reconstruct defects in the hard palate. These include mucoperiosteal aps, mucoperiosteal releasing incisions, local aps from the soft palate, buccal mucosal aps, and double reposition aps.7,8,15-18

Mucoperiosteal Flaps and Releasing Incisions


Mucoperiosteal aps are relatively simple to perform, being mindful of the location of the palatine artery medial to the carnassial tooth. While a single overlapping mucoperiosteal ap may be used,7 this may interfere with bone union in the case of cleft palate.19 Achieving a two-layer closure is preferable to allow a more anatomic closure and potentially allow osseous bridging of the bone defect.19 Bipedicle aps are most often used for closing cleft palate defects involving the hard palate (Fig. 1). They are easily

Figure 1 (A) Incisions are created medially and laterally in the mucoperiosteum of the hard palate. (B) The bipedicle aps are elevated, taking care to avoid the palatine artery. (C) Flaps are hinged and sutured to create the nasal mucosa, and the bipedicled aps are sutured to reconstruct the oral mucosa. The donor site defects are left open and epithelialize rapidly. (Color version of gure is available online.)

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Figure 2 (A) A hard palate mucosal ap is created with its base directed caudally. Incisions are placed to preserve the palatine artery. (B) Following elevation, the ap is rotated in to the defect and sutured. (Color version of gure is available online.)

A rotational ap may be elevated from the hard palate.20 The hard palate mucosal ap has its base directed caudally. The edges of the defect are debrided to expose the cut edge of the epithelial surface. The ap is simply rotated in to the defect and sutured primarily (Fig. 2). If the palatine artery is preserved, a long thin ap may be harvested and even rotated

180 to assist in closing large defects16 (Fig. 3), making this ap similar to an axial pattern ap.

Local Flaps from the Soft Palate


In a case reported by Beck and Strizek,16 a large caudal defect of the hard palate was covered using a hinged soft palate

Figure 3 (A) Diagram of the hard palate showing the full-thickness defect (B) and the proposed hinge ap of the soft palate (A). The arrow indicates the proposed rotation of the ap. (B) The soft palate ap has been hinged in to the defect (A) and the partial thickness defect in the soft palate remains open. (C) The proposed mucoperiosteal ap from the hard palate. Arrow indicates the proposed rotation of the ap. (C) The mucoperiosteal ap has been rotated in to the defect and sutured (A). The mucosal defect in the hard palate was left open (B), and the donor site in the soft palate was partially closed (C). Reprinted with permission.5

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Figure 4 (A) Flap incisions are extended caudally from the debrided defect in to the soft palate, creating a partialthickness advancement ap. (B) The ap is advanced and sutured primarily. (Color version of gure is available online.)

mucosal ap. Similar to hinging of mucoperiosteum adjacent to smaller defects to reconstruct the nasal mucosa, a hinged ap was created with its base at the caudal edge of the hard palate. The ap was created and elevated, incorporating approximately three-quarters of the thickness of the soft palate. The ap was folded forward so that the mucosal surface lined the oor of the nasal cavity, and sutures placed through bone tunnels were drilled in the hard palate. The majority of the donor site was closed primarily. With subsequent reconstruction of the oral mucosa using a mucoperiosteal rotation ap, a two-layer closure was achieved16 (Fig. 3). A simple advancement ap of the caudal hard palate and part of the soft palate has been described to close caudal midline hard palate defects.3 Advancement ap incisions are extended caudally, and a ap is elevated comprising a partial thickness of the soft palate. The dissection extends far enough to be able to mobilize sufcient tissue cranially to close the defect without tension3 (Fig. 4).

tension-free closure of the defect.21 Undermining should occur deep within the connective tissue to preserve vascularity to the ap.3 The ap is sutured to the mucoperiosteum of the hard palate in one or two layers of simple interrupted sutures. Buccal mucosal transposition aps based at the palatoglossal arches, as described by Sager and Nefen5 for correction of soft palate defects (see Buccal mucosal aps for the soft palate), have also been used by the author to reconstruct caudal

Buccal Mucosal Flaps


Buccal mucosal aps are very versatile aps, are routinely used in conjunction with maxillectomies, and are often performed for reconstruction of defects following resection of oral tumors (Fig. 5). They are also useful for closing oronasal stulae associated with tooth removal. Simple advancement aps are most common. The dissection is begun at the lateral edge of the defect and extended toward the lip margin. Labial mucosa and submucosa are separated from the remainder of the lip, and the ap is undermined sufciently to allow a

Figure 5 A large buccal mucosal advancement ap has been used to close a defect resulting from a left-sided maxillectomy.

Reconstruction of the hard and soft palate


hard palate defects. Random-pattern buccal mucosal transposition aps have been used previously to close large rostral hard palate defects.15

65 mined by the width of the soft palate defect. The incision is continued in a dorsoventral direction with the width of the ap being determined by the craniocaudal length of the defect in the soft palate. An incision parallel to the rst one is then made back to the base of the ap. The length and width of the ap are designed to be greater than the length and width of the defect to allow for shortening of the ap as it is rotated to avoid tension on the suture line. The ap is undermined and elevated bluntly, taking care to avoid the deep facial vein.5 If this ap includes the angularis oris artery and vein, it may be considered an axial pattern ap1 (see Angularis oris axial pattern buccal ap). The free edge of the soft palate defect is incised to create nasal and oral edges for suturing. One ap is rotated so that the mucosal side forms the oor of the nasopharynx, and the other is rotated such that it forms the roof of the oropharynx. The aps are sutured to the soft palate and nasopharyngeal mucosa using simple interrupted sutures. If the aps are reconstructing the caudal edge of the soft palate, the caudal edges of both aps are sutured to each other. The donor sites are closed using a simple interrupted suture pattern.5

Double Reposition Flap


Combinations of the previously mentioned hard palate hinged aps and buccal mucosal aps may be used to achieve double-layer closure of defects.17 The mucoperiosteum is incised for the planned ap to be 2 mm larger than the defect. The mucoperiosteum is elevated from the palate to the margin of the stula while preserving the basilar attachment of the ap which serves as a hinge. After suturing the hinged ap in to the defect, a simple buccal mucosal advancement ap is created and used to cover the hinged ap and denuded palatine bone. It is sutured to gingival and palate mucosa using simple interrupted sutures17 (Fig. 6). While a single-layer closure may be more prone to dehiscence than double-layer closures, it is often adequate for closure of defects if used in the absence of tension. Most defects are successfully repaired if aps can be apposed without tension and with a good blood supply.20

Local Flaps for the Soft Palate


Local aps that have been used in the soft palate include soft palate mucosal aps and releasing incisions, buccal mucosal aps, and pharyngeal wall aps.5,6,22,23 If possible, three-layer closures of the soft palate are preferred with sutures in the nasal mucosal, palatine muscles, and oral mucosa.19

Pharyngeal Wall Flaps


Pharyngeal wall aps may also be used to reconstruct large defects in the soft palate. Hammer and Sacks22 reported on the use of a pharyngeal wall ap with the base dorsal to the tonsillar crypt. This technique was used to reconstruct a unilateral congenital cleft of the soft palate. The technique was subsequently modied to include bilateral pharyngeal wall aps and a caudally hinged hard palate mucoperiosteal ap for reconstruction of a bilateral hypoplastic soft palate in a cat.23 A ap of mucoperiosteum was created in the caudal hard palate, approximately 2 cm in length and extending from the left to right dental arcades. Care was taken to preserve the palatine arteries. The ap was hinged 180 caudally to form the dorsal surface of the reconstructed soft palate. Bilateral aps were created in the pharyngeal mucosa in the right and left pharyngeal walls. The base of each ap extended from the caudal border of the last molar to the cranial border of the tonsillar crypt. The dimensions of each ap were sufcient to be able to suture them across the nasopharynx in an H-plasty conguration over the mucoperiosteal ap, thereby approximating dimensions of a normal soft palate.23 The ap base may be extended further caudally than the cranial border of the tonsillar crypt.22 The incision is extended to deep within the submucosa to preserve the vascular supply.22 The lateral edges of the mucoperiosteal ap were sutured to the edges of the pharyngeal wall, in the defects left by the creation of the pharyngeal aps. The pharyngeal aps were then sutured over the mucoperiosteal ap and to the caudal border of the ap. Donor sites in the hard palate and pharyngeal walls were left open.22,23

Soft Palate Mucosal Flaps and Releasing Incisions


This technique is often used to reconstruct cleft palate defects involving the soft palate. Incisions are created in the nasal side and oral side of opposite sides of the defect. Mucosal aps are elevated from the nasal mucosa on one side, and oral mucosa on the other. This will create two aps, one based on the oral side and the other on the nasal side of the defect. The width of each mucosal ap is 3 to 6 mm. The soft palate may then be approximated and sutured in three layers. Simple interrupted sutures are used with the knots placed on the nasal side of the mucosa, simple interrupted sutures in the palatine muscles, and the same pattern and sutures placed on the oral side. The result is a three-layer closure with offset suture lines19 (Fig. 7). Double-layer closures have also been used.6 Similar to releasing incisions in the hard palate mucoperiosteum, releasing incisions may also be performed in the soft palate. The incisions are extended through the mucosa of the oropharyngeal mucosa of the soft palate, and through the tensor veli palatini muscle. The incisions are extended caudally to the caudal edge of the nasopharynx19 (Fig. 7).

Buccal Mucosal Flaps for the Soft Palate


Buccal mucosal transposition aps may be elevated bilaterally, based at the palatoglossal arches5 (Fig. 8). This technique may be used for large defects in the soft palate. An incision is made in the mucosa with the base at the palatoglossal arch, at the level of the caudal end of the hard palate. The length of the incision (and length of the ap) is deter-

Axial Pattern and Distant Flaps


Few axial pattern aps have been described in the literature for reconstruction of the palate.1,9 The most versatile of these is the angularis oris axial pattern buccal ap.1

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Figure 6 (A) A mucoperiosteal ap is created (dotted line) to hinge it in to the defect. (B) The hinged ap is sutured in to the defect and a buccal mucosal advancement ap is created in the adjacent tissue. (C) The buccal mucosal ap is used to cover the hinged ap and exposed palatine bone. (Color version of gure is available online.)

Reconstruction of the hard and soft palate

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Figure 7 (A) Incisions are created in the nasal and oral side of opposite sides of the defect in the soft palate. (B) Two aps are created, one based on the oral side of the defect and the other on the nasal side of the defect. (C) The soft palate is sutured in three layers with sutures in the nasal mucosa, palatine muscles, and oral mucosa. Releasing incisions may be extended through the palatine muscles to decrease tension on the repair.

Angularis Oris Axial Pattern Buccal Flap


This axial pattern ap is based on the angularis oris artery and vein. It may be used to repair defects in the hard and soft palate to the contralateral dental arcade, or to the distal gin-

gival margin of the canine tooth or beyond, depending on skull conformation.1 Advantages of the ap include its highly vascular and robust character, high degree of mobility, and a surface of tough buccal mucosa.1

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Figure 8 (A) A buccal mucosal transposition ap is created with the base at the palatoglossal arch. (B) It may be rotated and sutured to reconstruct large defects extending as far as the caudal edge of the soft palate. The donor site is closed using simple interrupted sutures. (Color version of gure is available online.)

The angularis oris artery is a branch of the facial artery and courses from near the cranial border of the masseter muscle to the ipsilateral commissure of the mouth (Fig. 9). A pulse may be palpated in the labial tissue caudal to the commissure of the lips.1 An incision is made through the skin over the artery from the commissure of the lips and extending caudally. The skin is reected dorsally and ventrally to expose the angularis oris artery and vein. If the artery is difcult to identify via visualization or palpation, it may be identied via transillumination of the tissue. A full-thickness incision is made through the remaining cheek tissue, dorsal and ventral to the angularis oris vessels, extending to the caudal extent of the buccal pouch, thus creating a rectangular ap attached by buccal mucosa at the caudal buccal margin. An island ap may be created by incising through the buccal mucosal at the caudal extent of the buccal pouch and undermining the cheek tissue. The dissection is continued caudally to a point at which the angularis oris vessels enter under the cranioventral border of the masseter muscle.1 The ap is mobilized into the defect and sutured in a single layer using simple interrupted sutures1 (Fig. 10). The donor site is closed in three layers. The oral mucosa and subcutaneous tissue are closed separately using simple continuous

Figure 9 The angularis oris artery branches from the facial artery and within the labial tissue extends to the commissure of the mouth.

Reconstruction of the hard and soft palate

69 ap, suturing aps to freshly incised tissue edges, avoiding placement of suture lines over the defect, and gentle tissue handling.

References
1. Bryant KJ, Moore K, McAnulty JF: Angularis oris axial pattern buccal ap for reconstruction of recurrent stulae of the palate. Vet Surg 32:113-119, 2003 2. Degner DA, Lanz OI, Walshaw R: Myoperitoneal microvascular free aps in dogs: an anatomical study and a clinical case report. Vet Surg 25:463-470, 1996 3. Harvey CE: Palate defects in dogs and cats. Compend Contin Educ Pract Vet 9:404-418, 1987 4. Luskin IR: Reconstruction of oral defects using mucogingival pedicle aps. Clin Tech Small Anim Pract 15:251-259, 2000 5. Sager M, Nefen S: Use of buccal mucosal aps for the correction of congenital soft palate defects in three dogs. Vet Surg 27:358-363, 1998 6. Grifths LG, Sullivan M: Bilateral overlapping mucosal single-pedicle aps for correction of soft palate defects. J Am Anim Hosp Assoc 37: 183-186, 2001 7. Howard DR, Davis DG, Merkley DF, et al: Mucoperiosteal ap technique for cleft palate repair in dogs. J Am Vet Med Assoc 165:352-354, 1974 8. Knight G: Surgical closure of the cleft palate. Vet Rec 70:680-681, 1958 9. Dundas JM, Fowler JD, Shmon CL, et al: Modication of the supercial cervical axial pattern skin ap for oral reconstruction. Vet Surg 34:206213, 2005 10. Robertson JJ, Dean PW: Repair of a traumatically induced oronasal stula in a cat with a rostral tongue ap. Vet Surg 16:164-166, 1987 11. Coles BH, Underwood LC: Repair of the traumatic oronasal stula in the cat with a prosthetic acrylic implant. Vet Rec 122:359-360, 1988 12. Hobson HP, Heller RA, Wilson JB: Use of a removable maxillary appliance to correct a palatal defect in a dog. Vet Med Small Anim Clin 66:1085-1087, 1971 13. Smith MM, Rockhill AD: Prosthodontic appliance for repair of an oronasal stula in a cat. J Am Vet Med Assoc 208:1410-1412, 1996 14. Thoday KL, Charlton DA, Graham-Jones O, et al: The successful use of a prosthesis in the correction of a palatal defect in a dog. J Small Anim Pract 16:487-494, 1975 15. Banks TA, Straw RC: Multilobular osteochondrosarcoma of the hard palate in a dog. Aust Vet J 82:409-412, 2004 16. Beck JA, Strizek AA: Full-thickness resection of the hard palate for treatment of osteosarcoma in a dog. Aust Vet J 77:163-165, 1999 17. Ellison GW, Mulligan TW, Fagan DA, et al: A double reposition ap technique for repair of recurrent oronasal stulas in dogs. J Am Anim Hosp Assoc 22:803-808, 1986 18. Ishikawa Y, Goris RC, Nagaoka K: Use of a cortico-cancellous bone graft in the repair of a cleft palate in a dog. Vet Surg 23:201-205, 1994 19. Nelson AW: Cleft palate, in Slatter D (ed): Textbook of Small Animal Surgery, vol 1 (ed 3). Philadelphia, PA, Saunders, 2003, pp 814-823 20. Hedlund CS: Surgery of the oral cavity and oropharynx, in Fossum TW (ed): Small Animal Surgery (ed 2). St. Louis, MO, Mosby, 2002, pp 274-307 21. Salisbury SK: Maxillectomy and mandibulectomy, in Slatter D (ed): Textbook of Small Animal Surgery, vol 1 (ed 3). Philadelphia, PA, Saunders, 2003, pp 561-572 22. Hammer DL, Sacks M: Surgical closure of cleft soft palate in a dog. J Am Vet Med Assoc 158:342-345, 1971 23. Headrick JF, McAnulty JF: Reconstruction of a bilateral hypoplastic soft palate in a cat. J Am Anim Hosp Assoc 40:86-90, 2004

Figure 10 An angularis oris axial pattern ap is shown rotated in to a caudal hard palate defect, following resection of a large palate melanoma.

sutures. The skin is closed routinely. A single 2/0 nylon vertical mattress suture is placed at the commissure of the lips to protect the closure against tension when the mouth is opened.1 The supercial cervical axial pattern skin ap has also been modied for oral reconstruction. It requires the use of a pneumatic dermatome and is performed as a staged procedure.9

Postoperative Care
Intravenous uids should be provided until the animal is eating and drinking, usually within 24 to 48 hours of surgery. Soft food is given for 2 to 4 weeks, and chewing on hard objects must be prevented. An Elizabethan collar should be used if the animal is pawing at the mouth. Antibiotics are not required in most cases, although they may be used for cases of severe rhinitis. Healing should be evaluated 2 to 4 weeks after surgery.20 Use of a feeding tube should be considered following major repairs.

Summary
Defects of the hard and soft palate may result from a number of different etiologies. It is possible to primarily repair the majority of defects, although a variety of techniques may need to be combined for repair of large defects. An understanding of the different reconstructive techniques available is imperative to plan the surgical procedure. Complications are minimized by adhering to basic principles of palate surgery, which include making aps slightly larger than the defects to be reconstructed, maintaining vascularity to the

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