Abstract
Background/Aim: The treatment of squamous cell carcinoma (SCC) in the oral cavity for operable patients usually consists of surgical tumor resection, unilateral or bilateral neck dissection and defect reconstruction. In addition to local flaps, multiple, particularly microsurgical, distant flaps have been developed, which are mainly considered state of the art reconstruction. However, depending on previous operations and individual patient factors, microsurgical reconstruction is sometimes not suitable. Case Report: A 54-year-old male presented to the Department of Oral and Maxillofacial Surgery with leukoplakia-like changes in the area of the soft palate. Radiological and histopathological findings revealed SCC of the soft palate. Due to the patient’s reduced general condition, pronounced vasosclerosis and the patient’s negative opinion towards microsurgical reconstruction, the indication for tumor resection with simultaneous temporalis flap reconstruction was made. The temporalis flap showed sufficient healing throughout the follow up. Conclusion: For patients who are unsuitable for microsurgery (previous operations, radiation, patient’s request), well-known local flaps such as the temporalis flap represent more than an alternative treatment for defect reconstruction. The temporalis flap is particularly suitable for defect reconstruction of the maxilla and palate due to its easy flap raising and low complication rates. This case report shows the step-by-step flap raising of temporalis flap for soft palate reconstruction.
Squamous cell carcinoma (SCC) of the head and neck region is one of the most common tumors (1). The localization is diverse, particularly in the oral cavity (2). The tongue or the floor of the mouth are among the most commonly affected anatomical regions (2). Known risk factors for the development of SCC of the oral cavity are smoking and alcohol (1). However, chronical oral mucosal diseases or human papilloma virus (HPV) infections also predispose to the development of SCC in the oral cavity (1).
The symptoms of oral cavity tumors can be varied. In particular, diffuse pain, bleeding, swelling of the head and neck region or even persisting red (erythroplakia) or white mucosal changes (leukoplakia) are suspicious for SCC and require immediate clarification in a Department for oral and maxillofacial surgery (3).
After the histopathological confirmation of the SCC, radiological imaging (computed tomography/magnetic resonance imaging of the head/neck/abdomen region) is crucial in therapy planning to obtain indications of the progression of the tumor in the context of tumor staging (4, 5). The treatment of SCC in the oral cavity for operable patients usually consists of surgical tumor resection, unilateral or bilateral neck dissection, and one- or two-stage defect reconstruction in the respective anatomical localization (6, 7). In addition to local flaps, multiple, particularly microsurgical, distant flaps have been developed in recent decades, which are mainly considered “state of the art therapy” (8, 9). Some of the most common surgical distant flap techniques are the radial forearm flap and the osteomyocutaneous fibula flap (9). These can be used depending on the defect coverage (soft tissue, bone, mixture) and have various advantages and disadvantages as well as (contra-)indications (8, 9). However, depending on previous operations and individual patient factors (e.g., recurrent SCC after operation and/or radiotherapy), microsurgical reconstruction is sometimes not suitable. These patients can sometimes be treated with a local flap reconstruction, as the following case report illustrates - the temporalis flap.
Case Report
The present case report describes a 54-year-old male who presented to the Department of Oral and Maxillofacial Surgery with leukoplakia-like changes in the area of the soft palate extending into the uvula. The patient had a history of squamous cell carcinoma of the mandible, which was treated in our Department 8 years ago by mandibular continuity resection, bilateral neck dissection, mandibular reconstruction using an osteomyocutaneous fibula transplant, as well as adjuvant radiotherapy. Written informed consent was obtained from the patient.
The patient had a significant nicotine history (30 pack years). The first years of follow-up were unremarkable, with no evidence of local recurrence or near/distant metastasis. As part of the current presentation, the patient described intermittent pain in the area of the soft palate, particularly on the left side, for several weeks. An excision was performed in the area of the soft palate that revealed SCC. The computer tomography showed a clearly defined tumorous mass in the area of the soft palate, extending to the uvula.
A local recurrence of the primary SCC in the mandible could be ruled out. The extended imaging also revealed the findings of a tumorous process in the area of the left arytenoid cartilage. An excision was also carried out by the Ear-Nose-Throat Department with the findings of SCC. Due to these findings, the diagnosis of SCC of the soft palate and arytenoid cartilage was made as part of a second/third carcinoma.
Due to the patient’s reduced general condition, pronounced vasosclerosis with fumatorium, and the patient’s negative opinion towards another microsurgical reconstruction, the indication for tumor resection with simultaneous local flap reconstruction was made regarding the SCC of the soft palate. Due to the extent of the palate tumor, the defect was covered using a temporalis flap from the left for plastic reconstruction. The tumor resection of the palate tumor, a re-neck dissection on both sides, and the plastic reconstruction of the defect using a temporalis flap were carried out from the left (Figure 1, Figure 2, Figure 3, and Figure 4). When the temporalis flap was tunneled intraorally, an osteotomy of the zygomatic arch was performed with subsequent osteosynthesis. The postoperative course did not show any complications nor a flap loss. The flap showed sufficient perfusion and healing during the follow-up. Furthermore, the patient underwent resection of the tumor on the arytenoid cartilage by the ENT Department as well as adjuvant radiation for both SCCs.
Surgical approach to temporalis flap. The temporalis muscle is accessed via a preauricular incision that is made above the ear and over the temporal line. The skin and subcutis are then dissected away from the temporalis fascia until the entire muscle with the temporalis fascia is exposed.
Osteotomy of the zygomatic arch. Exposure and prophylactic osteotomy of the zygomatic arch on the left side to tunnel the muscle flap intraorally. Furthermore, an osteosynthesis plate can be adjusted and the corresponding pre-drillings can be made. It is particularly important to protect the zygomatic and frontal nerves (facial nerve in the right picture).
Temporalis flap raising. Representation of the muscle and drawing of the transplant on the fascia (left image). To raise the temporalis flap, the cranial end of the flap is incised at the level of the temporal line and the flap is lifted epiperiosteally from the skull.
Intraoral tunneling & defect coverage of soft palate. Entry with a clamp intraorally after a vestibular oral mucosal incision in the area of the left maxilla. The flap is then tunneled intraorally and sutured into the soft palate defect.
Discussion
In recent years, many different local and especially distant flaps have been continuously developed. Depending on the indication, microsurgical distant flaps in particular often represent the “state of the art” therapy for the reconstruction of extensive soft and hard tissue defects in the head and neck region (9). A prerequisite for microsurgical anastomization is, for example, sufficient connecting vessels in the reconstruction region, which are limiting for this form of reconstruction, especially in irradiated and/or previously operated patients or poor vascular status in the case of extensive vasosclerosis (9, 10).
One of the most frequently used distant flaps is the radial forearm flap, which is used especially for soft tissue reconstruction (8, 10). Due to its small thickness, easy flap elevation, and good perfusion, it is also ideal for covering palatal defects (10). However, this flap is only recommended to a limited extent if there is pronounced vasosclerosis in the donor and/or defect area (8, 10).
For more pronounced soft tissue defects in the head and neck region, the latissimus dorsi flap or the septocutaneous (para-)scapula flap represent a possible microsurgical distant flap reconstruction opportunity (10-12). If there is also a hard tissue defect, for example as part of a mandibular continuity resection, the scapula flap mentioned can also be used as an osteocutaneous transplant (10, 13). One of the most frequently used microsurgical distant flaps, particularly for severe mandibular defects, is the osteocutaneous fibula transplant (14). The healing rates of this defect reconstruction are up to 90% and therefore, show satisfactory results (14). However, since previously mentioned operations and/or radiation, as in this case study, are limiting for microsurgical defect reconstruction, well-known local flaps often represent an alternative treatment strategy.
An elegant variant for defect reconstruction in the area of the maxilla and palate is the so-called facial artery musculomucosal flap (FAMM flap) (15, 16). This local flap, consisting of (sub-)mucosa and buccinator muscle, can be used in many tumors of the oral cavity and is also a useful alternative to distant flaps in patients with previous radiation and/or neck dissection (17). The FAMM flap can also be combined with other flaps. Furthermore, this flap only shows rare vascular complications (17). Accordingly, complete flap losses and/or flap necrosis can be described as rare (17).
In addition to the FAMM flap, there is also the temporalis flap already described above as a local flap reconstruction technique (Figure 1, Figure 2, Figure 3, and Figure 4). The advantages of the temporalis flap are, in particular, the ease of flap raising, the relatively short operation time of the flap, and the subtle restrictions and/or complications postoperatively. However, the osteotomy of the zygomatic arch described in this case report does not always have to be chosen as part of the flap raising/tunneling (18). One of the most common aesthetic complications is postoperative “temporal hollowing” as an expression of a lack of volume in the region of origin of the temporal muscle (19, 20). This promotes the appearance of facial asymmetry. In some cases, expanders can be used in this area to prevent this complication (20). Further complications include subtle scarring and possible damage to the motor branches of the facial nerve (especially the zygomatic and frontal branches). Severe negative impairments in chewing function as a result of intraoral temporalis flaps have not yet been described. Complete flap losses and/or flap necrosis as well as speech problems/articulation problems with correct surgical flap raising and defect coverage are considered rare complications with this technique (21).
Conclusion
Microsurgical distant flap reconstructions of the oral cavity after tumor resections are considered standard therapy in cranio-maxillofacial surgery. For patients who are unsuitable for microsurgery (previous operations, radiation, patient’s request), well-known local flaps such as the temporalis flap represent more than an alternative treatment for the plastic reconstruction of these defects. The temporalis flap is particularly suitable for defect reconstruction of the maxilla and palate due to its easy flap raising and low complication rates.
Footnotes
Authors’ Contributions
KOH, FB, and FD treated the patient and revised the article. FD and FB researched the scientific literature, provided intraoperative findings, and wrote the article. All Authors gave final approval for publication.
Conflicts of Interest
The Authors have no relevant financial or non-financial interests to disclose in relation to this study.
Funding
The Authors declare that no funds, grants, or other support were received during the preparation of this manuscript.
- Received October 26, 2023.
- Revision received November 22, 2023.
- Accepted November 23, 2023.
- Copyright © 2024 The Author(s). Published by the International Institute of Anticancer Research.
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
References
In this issue
Jump to section
Related Articles
Cited By...
- No citing articles found.