Functional outcomes following palatal reconstruction with a folded radial forearm free flap.

Abstract

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearm free flaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients we re evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a sot diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative .]'or reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.

Introduction

Resection of a significant portion of the soft palate is often required during radical excision of large oropharyngeal tumors. The resultant disruption of valvular function of the sort palate leads to disturbed speech, characterized by hypernasality, and difficulty in swallowing as a result of nasal regurgitation. (1-3) The conventional solution to this problem has been to obturate this area with a palatal prosthesis. A prosthetic obturator is used (1) to fill small defects in the soft palate without encroaching on the lateral pharyngeal wall, (2) to repair reconstructive surgical failures (e.g., scarring or fistulization), (3) to treat patients with medical contraindications to prolonged general anesthesia, and (4) in treat patients who refuse reconstructive surgery. (4)

Its benefits notwithstanding, placement of a palatal prosthesis has several disadvantages, including discomfort, malodor as a result of the accumulation of debris on the surface of the prosthesis, persistent velopharyngeal insufficiency (particularly in patients with large defects), the elimination of sensory feedback from the intact mucosa of the bard palate, and the social awkwardness inherent in having a large oral prosthesis.

To circumvent some of these problems, many surgical techniques have been attempted over the past several decades for reconstruction of the soft palate. (1,2,5,6) Both local and distant tissue, including microvascular free flaps, have been used for this purpose. Some of these flaps provide a limited amount of tissue, most of them are nonsensate, and all of them are adynamic. Several of these procedures are performed in a staged fashion. None has been accepted universally.

We have reconstructed the soft palate by using a folded radial forearm free flap, and we have found that this technique is an excellent single-stage method for restoring bilateral epithelium-lined ports that connect the nasopharynx and oropharynx. In this article, we report the results of out study to determine functional outcomes--including speech and swallowing function--following such reconstruction of the soft palate.

Patients and methods

Patients. We performed soft-palate and oropharyngeal reconstruction by using a radial forearm free flap in 16 patients, aged 43 to 72 years (median: 54), between January 1997 and October 2001 in the Department of Otolaryngology-Head and Neck Surgery at the Keck School of Medicine of the University of Southern California. All patients underwent resection of the soft palate as a treatment for squamous cell carcinoma of the oropharynx. All of the primary tumors were staged as either T3 or T4 according to the American Joint Committee on Cancer Staging's TNM classification system. (7)

Five patients underwent radiotherapy preoperatively, and the remainder underwent radiotherapy postoperatively. All reconstructions were performed at the time of primary tumor ablation. Nine patients had partial soft-palate defects and 7 had total soft-palate defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had partial tongue defects near the tonsillolingual sulcus. All patients underwent tracheotomy and placement of a gastric tube prior to resection of the primary tumor.

Patients were followed for a period ranging from 3 to 40 months. Outcome measures were based on several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist by bedside swallowing examinations and flexible nasopharyngoscopy. In addition, 12 patients underwent videofluoroscopy. All patients underwent speech and swallowing therapy for 2 to 12 weeks.

Surgical technique. Resection of the primary tumor was performed in conjunction with ipsilateral or bilateral cervical lymph node dissection. The design of the radial forearm free flap was based on the size of the surgical defect of the sort palate, pharyngeal wall, and tongue base. The distance between the posterior border of the hard palate and the posterior pharyngeal wall was measured, as was the transverse defect of the palate, pharyngeal wall, and tongue base. These measurements were used to determine the exact dimensions of the radial forearm free flap, which was centered along the axis of the radial artery (figure 1). The distal portion of the flap was at least twice as wide as the distance between the posterior border of the hard palate and the posterior pharyngeal wall.

[FIGURE 1 OMITTED]

It is imperative that the portion of the skin flap that is used to reconstruct the soft palate is harvested with great redundancy to ensure that there is a broad area of contact between the folded free edge of the flap and the posterior pharyngeal wall. The radial forearm flap was harvested in the standard fashion. The medial or lateral antebrachial cutaneous nerve was harvested with the flap for restoration of sensation when the glossopharyngeal or greater palatine nerve at the recipient site could be preserved.

Insetting of the flap was begun at the posterior border of the hard palate, where the cephalad edge of the skin flap was sutured to the mucoperiosteum of the nasal side of the hard palate. The forearm skin paddle was then folded on itself, and the opposite margin was sutured to the mucoperiosteum of the oral side of the hard palate, thus creating both nasopharyngeal and oropharyngeal epithelial surfaces (figure 2). The opposing surfaces of the folded edge of the flap and the posterior pharyngeal wall were then deepithelialized. These two de-epithelialized surfaces were sutured to achieve a broad contact area (width: >2 cm) (figure 3). It is imperative that some degree of redundancy is maintained in this portion of the flap to ensure a tension-free apposition between the free edge of the flap and the posterior pharyngeal wall. The flap was inset to establish bilateral epithelium-lined ports that were capable of accommodating an 18 French catheter. As a result, communication between the nasopharynx and the oropharynx could be maintained. Following partial insetting, vascular and neural anastomoses were performed. The remainder of the flap was then inset in the pharyngeal and tongue-base defects.

[FIGURE 2 OMITTED]

Results

There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. All patients were evaluated by bedside swallowing evaluation and flexible nasopharyngoscopy 2 weeks after surgery. Four patients did not experience dysphagia, and they were able to resume oral intake. These 4 patients had partial soft-palate and lateral pharyngeal-wall defects. The 12 patients who did experience dysphagia underwent further examination with videofluoroscopy followed by swallowing therapy. Ten of these 12 patients were able to resume oral intake; the other 2 continued to experience severe dysphagia after 12 weeks of swallowing therapy, and they required a palatal prosthesis and functional rehabilitation. The surgical defects in these 2 patients involved the entire soft palate, the entire lateral pharyngeal wall, part of the posterior pharyngeal wall, and part of the base of the tongue.

Within 6 weeks, 10 patients were able to resume a normal diet and 4 were able to tolerate a soft diet. The 2 patients who received a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. Both of the patients with hypernasal speech underwent postoperative radiation therapy, which considerably reduced the volume of their respective radial forearm free flaps.

Discussion

The restoration of function following ablative surgery for oropharyngeal carcinoma presents a challenge to the head and neck reconstructive surgeon. The highly specialized tissues of the soft palate that control its complex motor activity and sensory feedback make it a difficult structure to duplicate. Resurfacing a mucosal defect does not restore the dynamic activity that is so critical to restoring the normal functions of this region.

Over the past century, numerous reconstruction techniques using local tissues have been tried in an attempt to restore palatal function in congenital velopharyngeal insufficiency. However, very little has been reported in the literature to date regarding the reconstruction of the soft palate following ablative surgery.

The pharyngeal flap considered to be the "workhorse" flap in treating congenital velopharyngeal insufficiency--has been described in the literature as a reconstructive option following palatopharyngeal resections, (8) commando procedures, (9) buccopharyngectomies, (10) subtotal or total palatectomies, (2) and palatal resections.] The use of the posterior pharyngeal flap was first described by Schoenborn in 1876 and again in 1886. (11) The use of this flap was later reported by Rosenthal (12) in 1924 and Padgett (13) in 1930. In 1935, Sanvenero-Rosselli popularized the use of the superiorly based posterior pharyngeal flap. (14) It was not until 1979 that Sofferman first reported the use of a modified pharyngeal flap in soft-palate reconstruction following cancer surgery. (8) Pharyngeal flap reconstruction of the soft palate always requires a second flap to line the undersurface of the pharyngeal flap.

Several other flaps have been used to reconstruct the soft palate following ablative surgery. They include the tongue flap, (6) the forehead flap, (5) the deltopectoral flap, (15) the palatal island flap, (16) the lateral pharyngeal flap, (17) the jejunal microvascular free flap, (18) and the cheek transposition flap. (1) More recently, radial forearm free flaps have been used for reconstructing the soft palate. (19-21) This most versatile sort tissue is harvested from the radial forearm donor site. The skin is thin, pliable, abundant, and well vascularized, which allows for considerable freedom in flap design and in accurate insetting. By extending the flap dimensions, the surgeon tan construct large areas of the lateral and posterior pharyngeal walls as well as the tongue base.

To achieve consistently superior functional results during reconstruction, several factors must be kept in mind. Some amount of redundancy of the radial forearm free flap should be maintained during reconstruction, particularly in patients who will later undergo postoperative radiotherapy. Radiation therapy can cause a considerable loss of flap volume and thereby raise the risk of velopharyngeal insufficiency, as was seen in 2 of our patients. Also, the free edge of the folded flap should be deepithelialized and sutured to the de-epithelialized posterior pharyngeal wall in order to maintain the bilateral ports that connect the nasopharynx and the oropharynx. The contact area between the flap and the posterior pharyngeal wall should span approximately 4 [cm.sup.2] to allow for optimum functional outcome.

Hyponasality can be eliminated by creating a lateral port whose circumference is approximately the same as that of an 18 French catheter. Shapiro et al created a resting velopharyngeal port that measured at least 20 [mm.sup.2] to assist in normal speech production following reconstruction of soft-palate defects with a superiorly based pharyngeal flap. (2) Hogan and Schwartz recommended that a lateral port should be no larger than 20 [mm.sup.2] in order to prevent velopharyngeal insufficiency during reconstruction of the sort palate in the treatment of cleft palate and other congenital or acquired defects at this site. (22)

To ensure that a radial forearm free flap is sensate, the medial or lateral antebrachial cutaneous nerve must be anastomosed to the glossopharyngeal or greater palatine nerve. Improved sensory feedback from the reconstructed soft palate may enhance the restoration of palatal function and facilitate deglutition and speech. Improved sensation can be achieved in a more predictable fashion by using a sensate radial forearm flap; this technique has been documented in several reports. (23,24) However, sensation is only one of many disturbed oral or pharyngeal functions that must be addressed before oral or pharyngeal rehabilitation can proceed to the next stage. Similarly, a loss of motor function after a total or subtotal pharyngectomy or palatectomy must also be addressed.

The application of microvascular free-tissue transfer has revolutionized the postablative and post-traumatic reconstruction of the head and neck region. The use of free flaps may very well expand what were previously considered to be the limits of palatal reconstruction as it has evolved over the past several decades.

References

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(19.) Sinha UK, Urken ML, Biller HF. Functional reconstruction of defects of the soft palate with a folded sensate radial forearm flap and a new classification system for oropharyngeal defects. Presented at the 4th International Conference on Head and Neck Cancer; July 28, 1996; Toronto.

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(23.) Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: Are we making sense? Plast Reconstr Surg 1994;93:1350-9; discussion 1360-2.

(24.) Sinha UK, Urken ML. Sensory recovery in microvascular free flaps for head and neck reconstruction. In; Meyers E, Bluestone CD, Brackmann DE, Krause C J, eds. Advances in Otolaryngology-Head and Neck Surgery. St. Louis: Mosby, 1997:41-58.

From the Department of Otolaryngology--Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles.

Reprint requests: Uttam K. Sinha, MD, Department of Otolaryngology--Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1200 N. State St., Box 795, Los Angeles, CA 90033. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Uttam K. Sinha, MD Philip Young, MD Keith Hurvitz, MD Dennis M. Crockett, MD