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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 difﬁcult 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 ﬂaps, 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 ﬂaps 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, ﬂap, 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 difﬁculties 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 ﬂap 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 ﬂap 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 ﬂaps large compared with the size of the defect to minimize tension. Preserve the vascular supply to ﬂaps 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: email@example.com
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 ﬂaps,3,5-8 axial pattern ﬂaps,1,9 distant tissue with use of a rostral tongue ﬂap,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 ﬂaps 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
These include mucoperiosteal ﬂaps. taking care to avoid the palatine artery. continuous with the nasal mucosal. The donor site defects are left open and epithelialize rapidly.8 The ﬂap has attachments maintained rostrally and caudally.K. and hinging it across the defect.18 although this step appears to be unnecessary. They are easily Figure 1 (A) Incisions are created medially and laterally in the mucoperiosteum of the hard palate.7 this may interfere with bone union in the case of cleft palate. being mindful of the location of the palatine artery medial to the carnassial tooth. Incisions are also made approximately 2 mm away from the edge of the midline defect. The bipedicled ﬂaps may then be mobilized to reconstruct the oral mucosa.19 Local Flaps for the Hard Palate Numerous local ﬂaps have been used to reconstruct defects in the hard palate. The ﬂap is sutured primarily using simple interrupted sutures.) . A simple hingedﬂap is created by elevating the mucosa adjacent to the defect. and double reposition ﬂaps. and the bipedicled ﬂaps are sutured to reconstruct the oral mucosa.19 Achieving a two-layer closure is preferable to allow a more anatomic closure and potentially allow osseous bridging of the bone defect.7.19 A bone free-graft from the medial tibia has been placed between the reconstructed oral and nasal mucosa to encourage bone formation. being careful to avoid the palatine artery.19 It is unnecessary to repair the resulting lateral defects with exposed palatine bone since these defects will epithelialize rapidly. (B) The bipedicle ﬂaps are elevated. thereby reconstructing the nasal mucosal defect. Sivacolundhu created by performing releasing incisions in the hard palate mucosa longitudinally along the length of the defect. local ﬂaps from the soft palate.8. mucoperiosteal releasing incisions.8. (Color version of ﬁgure is available online. (C) Flaps are hinged and sutured to create the nasal mucosa. again using simple interrupted sutures.62 R.15-18 Mucoperiosteal Flaps and Releasing Incisions Mucoperiosteal ﬂaps are relatively simple to perform. 1). buccal mucosal ﬂaps. adjacent and medial to the dental arcade.19 Bipedicle ﬂaps are most often used for closing cleft palate defects involving the hard palate (Fig. While a single overlapping mucoperiosteal ﬂap may be used. Elevation of the ﬂap continues from medial to lateral.
Arrow indicates the proposed rotation of the ﬂap. Local Flaps from the Soft Palate In a case reported by Beck and Strizek.Reconstruction of the hard and soft palate 63 Figure 2 (A) A hard palate mucosal ﬂap is created with its base directed caudally. (Color version of ﬁgure is available online.20 The hard palate mucosal ﬂap has its base directed caudally. The arrow indicates the proposed rotation of the ﬂap. The ﬂap is simply rotated in to the defect and sutured primarily (Fig. 3). (B) The soft palate ﬂap has been hinged in to the defect (A) and the partial thickness defect in the soft palate remains open.) A rotational ﬂap may be elevated from the hard palate. (B) Following elevation. The edges of the defect are debrided to expose the cut edge of the epithelial surface. If the palatine artery is preserved. and the donor site in the soft palate was partially closed (C).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 ﬂap of the soft palate (A). Reprinted with permission. the ﬂap is rotated in to the defect and sutured. Incisions are placed to preserve the palatine artery. 2).5 . (C) The proposed mucoperiosteal ﬂap from the hard palate. making this ﬂap similar to an axial pattern ﬂap. The mucosal defect in the hard palate was left open (B). (C) The mucoperiosteal ﬂap has been rotated in to the defect and sutured (A). a long thin ﬂap may be harvested and even rotated 180° to assist in closing large defects16 (Fig.
3). Simple advancement ﬂaps are most common.64 R. are routinely used in conjunction with maxillectomies. With subsequent reconstruction of the oral mucosa using a mucoperiosteal rotation ﬂap. have also been used by the author to reconstruct caudal Buccal Mucosal Flaps Buccal mucosal ﬂaps are very versatile ﬂaps. Buccal mucosal transposition ﬂaps based at the palatoglossal arches. creating a partialthickness advancement ﬂap. a two-layer closure was achieved16 (Fig. tension-free closure of the defect. The ﬂap was created and elevated. The dissection extends far enough to be able to mobilize sufﬁcient tissue cranially to close the defect without tension3 (Fig. (Color version of ﬁgure is available online. and sutures placed through bone tunnels were drilled in the hard palate.3 Advancement ﬂap incisions are extended caudally. The dissection is begun at the lateral edge of the defect and extended toward the lip margin. as described by Sager and Nefen5 for correction of soft palate defects (see Buccal mucosal ﬂaps for the soft palate).) mucosal ﬂap. 4). a hinged ﬂap was created with its base at the caudal edge of the hard palate. The ﬂap was folded forward so that the mucosal surface lined the ﬂoor of the nasal cavity. The majority of the donor site was closed primarily. Sivacolundhu Figure 4 (A) Flap incisions are extended caudally from the debrided defect in to the soft palate. Labial mucosa and submucosa are separated from the remainder of the lip. and a ﬂap is elevated comprising a partial thickness of the soft palate. . and the ﬂap is undermined sufﬁciently to allow a Figure 5 A large buccal mucosal advancement ﬂap has been used to close a defect resulting from a left-sided maxillectomy. Similar to hinging of mucoperiosteum adjacent to smaller defects to reconstruct the nasal mucosa. They are also useful for closing oronasal ﬁstulae associated with tooth removal. incorporating approximately three-quarters of the thickness of the soft palate.K.21 Undermining should occur deep within the connective tissue to preserve vascularity to the ﬂap.3 The ﬂap is sutured to the mucoperiosteum of the hard palate in one or two layers of simple interrupted sutures. A simple advancement ﬂap of the caudal hard palate and part of the soft palate has been described to close caudal midline hard palate defects. 5). and are often performed for reconstruction of defects following resection of oral tumors (Fig. (B) The ﬂap is advanced and sutured primarily.
17 The mucoperiosteum is incised for the planned ﬂap to be 2 mm larger than the defect.6. buccal mucosal ﬂaps. The base of each ﬂap extended from the caudal border of the last molar to the cranial border of the tonsillar crypt. Care was taken to preserve the palatine arteries. and through the tensor veli palatini muscle. it may be considered an axial pattern ﬂap1 (see Angularis oris axial pattern buccal ﬂap).22.Reconstruction of the hard and soft palate hard palate defects.1. The soft palate may then be approximated and sutured in three layers. 7).6 Similar to releasing incisions in the hard palate mucoperiosteum. and the other is rotated such that it forms the roof of the oropharynx. three-layer closures of the soft palate are preferred with sutures in the nasal mucosal. one based on the oral side and the other on the nasal side of the defect. This technique was used to reconstruct a unilateral congenital cleft of the soft palate. and pharyngeal wall ﬂaps. An incision parallel to the ﬁrst one is then made back to the base of the ﬂap. Bilateral ﬂaps were created in the pharyngeal mucosa in the right and left pharyngeal walls. 7).20 Local Flaps for the Soft Palate Local ﬂaps that have been used in the soft palate include soft palate mucosal ﬂaps and releasing incisions.5. After suturing the hinged ﬂap in to the defect.5 Double Reposition Flap Combinations of the previously mentioned hard palate hinged ﬂaps and buccal mucosal ﬂaps may be used to achieve double-layer closure of defects. The donor sites are closed using a simple interrupted suture pattern. The result is a three-layer closure with offset suture lines19 (Fig. The width of each mucosal ﬂap is 3 to 6 mm.23 If possible. It is sutured to gingival and palate mucosa using simple interrupted sutures17 (Fig.23 A ﬂap of mucoperiosteum was created in the caudal hard palate. the caudal edges of both ﬂaps are sutured to each other. If the ﬂaps are reconstructing the caudal edge of the soft palate.19 Pharyngeal Wall Flaps Pharyngeal wall ﬂaps may also be used to reconstruct large defects in the soft palate. and oral mucosa. 6).23 The ﬂap base may be extended further caudally than the cranial border of the tonsillar crypt. at the level of the caudal end of the hard palate.9 The most versatile of these is the angularis oris axial pattern buccal ﬂap. An incision is made in the mucosa with the base at the palatoglossal arch. The ﬂaps are sutured to the soft palate and nasopharyngeal mucosa using simple interrupted sutures. palatine muscles. and the same pattern and sutures placed on the oral side. The incisions are extended through the mucosa of the oropharyngeal mucosa of the soft palate.23 Soft Palate Mucosal Flaps and Releasing Incisions This technique is often used to reconstruct cleft palate defects involving the soft palate. releasing incisions may also be performed in the soft palate. The incisions are extended caudally to the caudal edge of the nasopharynx19 (Fig. The dimensions of each ﬂap were sufﬁcient to be able to suture them across the nasopharynx in an “H-plasty” conﬁguration over the mucoperiosteal ﬂap. and oral mucosa on the other.22 The lateral edges of the mucoperiosteal ﬂap were sutured to the edges of the pharyngeal wall. The ﬂap is undermined and elevated bluntly. The incision is continued in a dorsoventral direction with the width of the ﬂap being determined by the craniocaudal length of the defect in the soft palate. The mucoperiosteum is elevated from the palate to the margin of the ﬁstula while preserving the basilar attachment of the ﬂap which serves as a hinge. The technique was subsequently modiﬁed to include bilateral pharyngeal wall ﬂaps and a caudally hinged hard palate mucoperiosteal ﬂap for reconstruction of a bilateral hypoplastic soft palate in a cat.22. thereby approximating dimensions of a normal soft palate. Double-layer closures have also been used. it is often adequate for closure of defects if used in the absence of tension.5 If this ﬂap includes the angularis oris artery and vein. Simple interrupted sutures are used with the knots placed on the nasal side of the mucosa. While a single-layer closure may be more prone to dehiscence than double-layer closures. a simple buccal mucosal advancement ﬂap is created and used to cover the hinged ﬂap and denuded palatine bone. 8). Donor sites in the hard palate and pharyngeal walls were left open. The length and width of the ﬂap are designed to be greater than the length and width of the defect to allow for shortening of the ﬂap as it is rotated to avoid tension on the suture line. Incisions are created in the nasal side and oral side of opposite sides of the defect. The length of the incision (and length of the ﬂap) is deter- Axial Pattern and Distant Flaps Few axial pattern ﬂaps have been described in the literature for reconstruction of the palate.1 . approximately 2 cm in length and extending from the left to right dental arcades. Hammer and Sacks22 reported on the use of a pharyngeal wall ﬂap with the base dorsal to the tonsillar crypt. Mucosal ﬂaps are elevated from the nasal mucosa on one side. The ﬂap was hinged 180° caudally to form the dorsal surface of the reconstructed soft palate.15 65 mined by the width of the soft palate defect. One ﬂap is rotated so that the mucosal side forms the ﬂoor of the nasopharynx. Random-pattern buccal mucosal transposition ﬂaps have been used previously to close large rostral hard palate defects.22 The incision is extended to deep within the submucosa to preserve the vascular supply. Buccal Mucosal Flaps for the Soft Palate Buccal mucosal transposition ﬂaps may be elevated bilaterally. Most defects are successfully repaired if ﬂaps can be apposed without tension and with a good blood supply. The free edge of the soft palate defect is incised to create nasal and oral edges for suturing. This technique may be used for large defects in the soft palate. This will create two ﬂaps. based at the palatoglossal arches5 (Fig. simple interrupted sutures in the palatine muscles. The pharyngeal ﬂaps were then sutured over the mucoperiosteal ﬂap and to the caudal border of the ﬂap. taking care to avoid the deep facial vein. in the defects left by the creation of the pharyngeal ﬂaps.
K. (C) The buccal mucosal ﬂap is used to cover the hinged ﬂap and exposed palatine bone. (Color version of ﬁgure is available online.66 R. (B) The hinged ﬂap is sutured in to the defect and a buccal mucosal advancement ﬂap is created in the adjacent tissue. Sivacolundhu Figure 6 (A) A mucoperiosteal ﬂap is created (dotted line) to hinge it in to the defect.) .
1 Advantages of the ﬂap include its highly vascular and robust character. It may be used to repair defects in the hard and soft palate to the contralateral dental arcade. palatine muscles. and a surface of tough buccal mucosa. Angularis Oris Axial Pattern Buccal Flap This axial pattern ﬂap is based on the angularis oris artery and vein. and oral mucosa.1 .Reconstruction of the hard and soft palate 67 Figure 7 (A) Incisions are created in the nasal and oral side of opposite sides of the defect in the soft palate. (B) Two ﬂaps are created. Releasing incisions may be extended through the palatine muscles to decrease tension on the repair. high degree of mobility. or to the distal gin- gival margin of the canine tooth or beyond. one based on the oral side of the defect and the other on the nasal side of the defect. depending on skull conformation. (C) The soft palate is sutured in three layers with sutures in the nasal mucosa.
Sivacolundhu Figure 8 (A) A buccal mucosal transposition ﬂap is created with the base at the palatoglossal arch.68 R. A pulse may be palpated in the labial tissue caudal to the commissure of the lips. The donor site is closed in three layers. 9). The skin is reﬂected dorsally and ventrally to expose the angularis oris artery and vein. 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.1 An incision is made through the skin over the artery from the commissure of the lips and extending caudally. If the artery is difﬁcult to identify via visualization or palpation. The donor site is closed using simple interrupted sutures. . dorsal and ventral to the angularis oris vessels. 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 ﬂap is mobilized into the defect and sutured in a single layer using simple interrupted sutures1 (Fig. (B) It may be rotated and sutured to reconstruct large defects extending as far as the caudal edge of the soft palate.) 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. (Color version of ﬁgure is available online. 10).K. extending to the caudal extent of the buccal pouch. thus creating a rectangular ﬂap attached by buccal mucosa at the caudal buccal margin. An island ﬂap may be created by incising through the buccal mucosal at the caudal extent of the buccal pouch and undermining the cheek tissue. it may be identiﬁed via transillumination of the tissue. A full-thickness incision is made through the remaining cheek tissue.
Nagaoka K: Use of a cortico-cancellous bone graft in the repair of a cleft palate in a dog. J Am Vet Med Assoc 165:352-354.20 Use of a feeding tube should be considered following major repairs. Vet Surg 16:164-166. et al: The successful use of a prosthesis in the correction of a palatal defect in a dog. Vet Med Small Anim Clin 66:1085-1087. Bryant KJ. in Fossum TW (ed): Small Animal Surgery (ed 2). Aust Vet J 77:163-165. 1987 4. Thoday KL. 1999 17. Rockhill AD: Prosthodontic appliance for repair of an oronasal ﬁstula in a cat. 2002. Sager M. 1987 11. Healing should be evaluated 2 to 4 weeks after surgery. sutures. 1971 23. An Elizabethan collar should be used if the animal is pawing at the mouth. 2001 7. Howard DR. Fowler JD. Hammer DL. Robertson JJ. which include making ﬂaps slightly larger than the defects to be reconstructed. Degner DA. McAnulty JF: Angularis oris axial pattern buccal ﬂap for reconstruction of recurrent ﬁstulae of the palate. Charlton DA. following resection of a large palate melanoma. It requires the use of a pneumatic dermatome and is performed as a staged procedure. Vet Rec 122:359-360. McAnulty JF: Reconstruction of a bilateral hypoplastic soft palate in a cat.1 The superﬁcial cervical axial pattern skin ﬂap has also been modiﬁed for oral reconstruction. Luskin IR: Reconstruction of oral defects using mucogingival pedicle ﬂaps. vol 1 (ed 3). 1996 14. Heller RA. 2003. Vet Surg 32:113-119. Soft food is given for 2 to 4 weeks. Moore K. et al: Modiﬁcation of the superﬁcial cervical axial pattern skin ﬂap for oral reconstruction.Reconstruction of the hard and soft palate 69 ﬂap. Harvey CE: Palate defects in dogs and cats. Ishikawa Y. pp 274-307 21. pp 814-823 20. An understanding of the different reconstructive techniques available is imperative to plan the surgical procedure. Sullivan M: Bilateral overlapping mucosal single-pedicle ﬂaps for correction of soft palate defects. et al: Mucoperiosteal ﬂap technique for cleft palate repair in dogs. pp 561-572 22. Strizek AA: Full-thickness resection of the hard palate for treatment of osteosarcoma in a dog. Straw RC: Multilobular osteochondrosarcoma of the hard palate in a dog. Graham-Jones O. Underwood LC: Repair of the traumatic oronasal ﬁstula in the cat with a prosthetic acrylic implant. Merkley DF. J Am Vet Med Assoc 158:342-345. Mulligan TW. Fagan DA. vol 1 (ed 3). Knight G: Surgical closure of the cleft palate. Vet Surg 23:201-205. Aust Vet J 82:409-412. in Slatter D (ed): Textbook of Small Animal Surgery. Dundas JM. 2004 Figure 10 An angularis oris axial pattern ﬂap is shown rotated in to a caudal hard palate defect. Vet Surg 25:463-470. Hobson HP. in Slatter D (ed): Textbook of Small Animal Surgery. J Am Anim Hosp Assoc 37: 183-186. suturing ﬂaps to freshly incised tissue edges. Dean PW: Repair of a traumatically induced oronasal ﬁstula in a cat with a rostral tongue ﬂap. PA. Complications are minimized by adhering to basic principles of palate surgery. Salisbury SK: Maxillectomy and mandibulectomy. Davis DG. Goris RC. Nefen S: Use of buccal mucosal ﬂaps for the correction of congenital soft palate defects in three dogs. References 1. Saunders. Headrick JF. 1998 6. although they may be used for cases of severe rhinitis. MO. Beck JA. maintaining vascularity to the . and chewing on hard objects must be prevented. J Small Anim Pract 16:487-494. avoiding placement of suture lines over the defect. J Am Vet Med Assoc 208:1410-1412. J Am Anim Hosp Assoc 22:803-808. 1971 13. Summary Defects of the hard and soft palate may result from a number of different etiologies. 1988 12. Mosby. 1986 18. 1975 15. Wilson JB: Use of a removable maxillary appliance to correct a palatal defect in a dog. 2000 5. 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. Smith MM. Ellison GW. Coles BH. 1974 8. Clin Tech Small Anim Pract 15:251-259. Sacks M: Surgical closure of cleft soft palate in a dog. Vet Rec 70:680-681. Vet Surg 27:358-363. 2003 2. Banks TA. J Am Anim Hosp Assoc 40:86-90. although a variety of techniques may need to be combined for repair of large defects. Hedlund CS: Surgery of the oral cavity and oropharynx. 1994 19. It is possible to primarily repair the majority of defects. Nelson AW: Cleft palate. The skin is closed routinely. 1996 3. Walshaw R: Myoperitoneal microvascular free ﬂaps in dogs: an anatomical study and a clinical case report.9 Postoperative Care Intravenous ﬂuids should be provided until the animal is eating and drinking. Philadelphia. PA. Philadelphia. 2004 16. 1958 9. Compend Contin Educ Pract Vet 9:404-418. 2003. Antibiotics are not required in most cases. and gentle tissue handling. Louis. Saunders. Vet Surg 34:206213. 2005 10. Lanz OI. et al: A double reposition ﬂap technique for repair of recurrent oronasal ﬁstulas in dogs. Grifﬁths LG. St. Shmon CL. usually within 24 to 48 hours of surgery.
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