Intraoral Flap Research Articles

Manual Hair Removal for Intraoral Flaps: a Simple Practice for Professional Education and Patient Cancer Care.

After resection of malignant tumors of the head and neck, reconstructions are commonly performed using surgical free flaps. In non-irradiated patients, hair may continue to grow at the reconstruction site after surgery, causing undesirable effects such as difficult to maintain oral hygiene, food and saliva accumulation, halitosis, dysphagia, moral distress, and impact on intimacy and sexuality. Until a standardized laser therapy protocol is available, manual depilation isan option that should not be underestimated to improve the patient's quality of life and available to every oral healthcare team. This case illustrates a simple practice that contributes to improving patients' quality of life and oral health in an interprofessional way.

Intra-Oral Flap Splint Fabrication: A 3D Printing and Digital Impression Approach

Intra-Oral Flap Splint Fabrication: A 3D Printing and Digital Impression Approach

Evaluation of the non-endoscopic and endoscopic-assisted platysma flap - A randomized control trial.

As oral submucous fibrosis (OSMF) is a chronic progressive disorder, the treatment is based on the severity of the disease. Surgical treatment is the only choice for grade III and grade IV OSMF cases because the patient can neither clean his/her mouth nor properly chew. The resulting soft tissue defect requires resurfacing with various well-vascularized tissues such as extraoral flaps, intraoral flaps, microvascular flaps, and allografts that have been used. Reconstruction of the resultant defects proved to be challenging. Till date, none of the flaps has been proven to be effective and is universally accepted for the treatment of OSMF because of various drawbacks of the available techniques. This study was conducted to know whether an endoscopic-assisted platysma flap is associated with better outcomes in terms of ease of operation and postoperative function than the conventional approach. This study included 40 patients of grade III and grade IV OSMF reporting to the outpatient department of oral and maxillofacial surgery in a tertiary center of North India. These patients were divided randomly into two groups. Group I and Group II had 20 patients each, undergoing endoscopic-assisted platysma flap and non-endoscopic-assisted platysma flap for reconstruction after resection of OSMF bands, respectively. Data were analyzed for the mouth opening, operating time, flap viability, congestion of neck and oral cavity, signs of inflammation, neurologic assessment, and measurement of the drain. The results showed significant increase in mouth opening from the preoperative value to the values immediately after surgery and at 24 h, 1 week, 15 days, 1 month, 3 months, and 6 months after surgery in both the study groups. Reduced bleeding incidence was found in group I compared to group II, with better postoperative outcomes noted during follow-up. But the mean intraoperative time of the subjects in group I was 130.80 ± 5.5.908 min and in group II was 105.74 ± 2. 491 min. Increased time taken in group I may be due to the long learning curve. The present study concluded that the Endoscope-assisted technique has a key role during supra and subplatysmal dissection to allow for better accessibility, handling, and visibility of the flap and its orientation in relation to the underlying structures to avoid postoperative complications and to overcome the drawback of platysma myocutaneous flap in reconstruction of OSMF defects.

Laser Hair Removal for Intraoral Flaps: A Review.

Importance: Laser hair removal is a noninvasive technique that has been used for patients with oropharyngolaryngeal hair growth related to surgical flap reconstruction after head and neck cancer resection. The purpose of this work was to perform a rapid review of the literature to determine the therapeutic relevance of laser hair removal and identify laser parameters. Observations: A total of 10 publications addressing depilation of the head and neck sphere were selected and analyzed. Conclusions and Relevance: Laser therapy appears to be a promising treatment for hair removal from flaps with few side effects. However, there is no scientific basis for a standardized protocol or determination of the superiority of laser hair removal over another treatment.

Flap perfusion monitoring with an attached surface probe in microvascular reconstruction of the oral cavity

ObjectivesPostoperative flap monitoring is essential in oral microvascular reconstruction for timely detection of vascular compromise. This study investigated the use of attached surface probes for the oxygen-2-see (O2C) analysis system (LEA Medizintechnik, Germany) for intraoral flap perfusion monitoring.Materials and methodsThe study included 30 patients who underwent oral reconstruction with a microvascular radial-free forearm flap (RFFF) or anterolateral thigh flap (ALTF) between 2020 and 2022. Flap perfusion was measured with attached (3-mm measurement depth) and unattached surface probes (2- and 8-mm measurement depths) for the O2C analysis system at 0, 12, 24, 36, and 48 h postoperatively. Flap perfusion monitoring with attached surface probes was evaluated for cut-off values for flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation indicative of vascular compromise and for accuracy and concordance with unattached surface probes.ResultsThree RFFFs were successfully revised, and one ALTF was unsuccessfully revised. The cut-off values indicative of vascular compromise for flap perfusion monitoring with attached surface probes were for RFFF and ALTF: blood flow < 60 arbitrary units (AU) and < 40AU, hemoglobin concentration > 100AU and > 80AU (both > 10% increase), and hemoglobin oxygen saturation < 40% and < 30%. Flap perfusion monitoring with attached surface probes yielded a 97.1% accuracy and a Cohen’s kappa of 0.653 (p < 0.001).ConclusionsFlap perfusion monitoring with attached surface probes for the O2C analysis system detected vascular compromise accurately and concordantly with unattached surface probes.Clinical relevanceAttached surface probes for the O2C analysis system are a feasible option for intraoral flap perfusion monitoring.

Clinical application of double V-Y advancement mucosal flap to repair tongue defect.

The repair of small- and medium-sized defects in the oral tongue has always been a challenge, and the effect of free flap and distal pedicle flap is still far from satisfactory. Tongue flap is an ideal choice for repairing small- and medium-sized defects. However, the disadvantages such as poor local morphology restricts the development of this operation.This study aims to investigate the efficacy of double V-Y advancement mucosal flap in repair of small- and medium-sized defects of the tongue defect. The clinical data of 15 patients with tongue defect lesions who were hospitalized in the Department of Stomatology, Third Xiangya Hospital of Central South University from March 2019 to May 2022 were retrospectively analyzed. After the lesions were completely excised, the mucosa and part of the tongue defect were left. One V-Y advancement mucosal flap was designed anteriorly and posteriorly to the defect. The superficial mucosa was incised gradually all around, preserving the deep median muscle tip. The 2 flaps were freed toward the middle of the defect, and the anterior and posterior flaps were sutured together at the middle of the defect, with the donor area directly pulled together and sutured. The double V-Y advancement mucosal flap survived in 15 patients, and the wounds healed at stage I. The postoperative follow-up time was 12-22 months, and the patients had no recurrence, with symmetrical tongue shape, and no traction and deformation in the affected tongue organs. Meanwhile, the intraoral flap was thin and flat, and healed well with the surrounding mucosa, without obvious flap contracture or tongue bite. Double V-Y advancement mucosal flap has the advantages of flexible design, simple preparation, reliable blood supply, and good protection of the donor site, which may be one of the effective methods for repairing small- and medium-sized defects in the anterior tongue mucosa.

V-shaped Folded Nasolabial Flap in the Repair of the Anterior Buccal Mucosal Defect.

To investigate the efficacy of V-shaped folded nasolabial flap in the repair of small-sized and medium-sized defects of the anterior buccal mucosa. From March 2019 to December 2021, 9 cases of male patients with anterior buccal mucosal lesions were enrolled in this study. After the lesions were completely excised, the mucosa and part of the buccal mucosal defect were left. A transverse V-shaped folded nasolabial flap was created with the pedicle located at the corner of the mouth and the long axis along the nasolabial fold. The lower part was lifted from the end to the pedicle. Next, from the level of the superficial musculo-aponeurotic system, the upper and lower parts were lifted from the end to the pedicle, and the V-shaped flap was folded and turned over through the buccal tunnel to repair the mucosal defect. The extraoral donor site was directly pulled and sutured. The nasolabial flap survived in 9 patients, and the wounds inside and outside the mouth healed at stage I. The postoperative follow-up time was 4 to 32 months, and the patients had no recurrence, with symmetrical buccal shape, and no traction and deformation in the affected buccal organs. In addition, the linear scar had no obvious hyperplasia and was hidden in the affected nasolabial folds, without symptoms of buccal nerve injury, and the shape of the corner of the mouth was normal. The width and opening degree of oral fissure were not significantly reduced compared with those before operation. Meanwhile, the intraoral flap was thin and flat, and healed well with the surrounding mucosa, without obvious flap contracture, buccal bite, or incomplete closure. Overall, V-shaped folded nasolabial flap has the advantages of flexible design, simple preparation, reliable blood supply, and protection of the donor site, which may be one of the effective methods for repairing small-sized and medium-sized defects in the anterior buccal mucosa.

Trimming of Facial Artery Myomucosal Flap (FAMM) using Indocyanine Green Fluorescence Video-Angiography: Operative Nuances.

Facial artery myomucosal flap (FAMM) is an intraoral flap pedicled on facial artery used for reconstruction of oral/oropharyngeal defects.1 Careful assessment of perfusion is essential to avoid flap necrosis, and several options are used for this purpose. Among these, indocyanine green (ICG) fluorescence video-angiography (ICG-VA) represents an innovative tool whose adoption in flap surgery is still at its early days.2 METHODS: In this multimedia article, we described the use of ICG-VA for perfusion assessment of a FAMM flap harvested for reconstruction of oral lining after ablation of a cT2cN0 floor-of-mouth (FOM) cancer. The use of ICG-VA was aimed at defining ischemic areas on the flap according to a flap-to-normal mucosa ICG ratio. After transoral excision of the FOM cancer and subsequent harvesting of a FAMM flap, we used ICG-VA to intraoperatively assess its perfusion. The degree of flap perfusion was expressed point-by-point through flap-to-normal mucosa ICG ratio (percentage); a value of 25-27% was considered as threshold for ischemia.3 Perfusion was documented both with white light modality with "overlay fluorescence" and "black and white SPY fluorescence mode" designed to increase the sensitivity of ICG detection. Small, ischemic areas were detected in the distal part of the flap and were trimmed. At the end of the procedure, an adequate perfusion was evident throughout the whole flap, allowing its safe insetting for left FOM reconstruction. Postoperative course was uneventful. ICG-VA represents a reliable tool for intraoperative detection-and trimming-of ischemic areas on reconstructive flaps.

Multilayered Closure of Oronasal and Oroantral Fistula Using Intranasal and Intraoral Flaps.

Multilayered Closure of Oronasal and Oroantral Fistula Using Intranasal and Intraoral Flaps.

Morphological Changes and Durability of Skin and Mucosal Flaps in Intraoral and Pharyngeal Reconstructions: Long-term Follow-up and Literature Review for Potential Second Carcinomas.

The long-term changes in tissues implanted in the oral cavity and pharynx after head and neck reconstruction have not been fully evaluated. This study aimed to clarify the morphological changes, long-term durability, and potential for secondary carcinogenesis in such tissues. In our single-center study, the rough morphological changes in 54 cases of intraoral and pharyngeal skin and mucosal flaps were evaluated more than 10 years after flap transfer. In addition, the literature on the development of second carcinomas from skin flaps was reviewed. The mean follow-up period for transferred flaps was 148 months. The reconstruction areas and the probability of morphological changes were significantly correlated (p=0.006), especially in cases with tongue, lower gingiva, and buccal mucosal reconstruction. Free jejunal flap surfaces were well maintained, whereas tubed skin flaps showed severe morphological changes in cases with pharyngeal reconstruction. None of the flaps in our series developed second primary carcinomas. Skin flaps generally had good durability for > 10 years in intraoral environments, while mucosal flaps had better durability for pharyngeal reconstruction. Second squamous carcinomas arising from skin flaps are extremely rare; however, surgeons should take this possibility into consideration and conduct meticulous and long-term follow-up.

Clinical and Histological Features of Intraoral Flap and a Preliminary Study of DNA Methylation of Mucosalization

Flaps have been routinely used to reconstruct intraoral defects. Flaps after reconstruction tend to develop, with time, a mucosa-like appearance during a process called “mucosalization.” Many studies have described histological changes of mucosalization, but only a few of them mention the associated clinical factors. Our aim was to determine the possible predictive factors related to mucosalization of flaps employed for oral cavity reconstruction, and to verify whether skin inflammation-specific DNA methylation occurs in mucosalized flaps. In this study, 140 patients underwent reconstruction of the oral cavity defects with flaps, of which 39 showed “mucosalization” changes. Histological changes of “mucosalization” are characterized by inflammatory infiltration, accompanied by a reduction of thickness of the horny layer and elimination of skin appendages. These changes are affected by clinical differences with sex and type and site of flaps. We also found that DNA methyltransferase 1 was highly expressed in the epithelium of mucosalized flaps, and less in unmucosalized flaps, suggesting their involvement in the inflammation-dependent DNA methylation of mucosalization. To summarize, our results demonstrated that most intraorally placed flaps maintain skin features, except in the event of heavy inflammation. Mucosalization varies in association with sex of the subject and type and site of flaps. DNA methyltransferase 1 might correlate with mucosalization, suggesting that DNA methylation may be involved in chronic inflammation in mucosalization.

Assessment of Clinical and Histological Changes in the Skin Paddle of Pectoralis Major Myocutaneous Flap in Intraoral Reconstruction: A Prospective Cohort Study.

This study was carried out to characterize the clinical and histological changes in the cutaneous portion of the transferred pedicled pectoralis major myocutaneous flaps used in intraoral reconstruction in patients with head and neck malignancy. This was a prospective cohort study carried out from July 2016 to 2018. All patients underwent ablative surgery for oropharyngeal cancers and primary reconstruction with pedicled pedicled pectoralis major myocutaneous flaps. The intraoral flaps were examined for color, texture, presence of hair, chronic inflammatory changes, and ulceration. At 12 months, incisional biopsies were taken from the skin paddle of the intraoral flap and contralateral normal buccal mucosa, and flap histology was compared with that of the contralateral buccal mucosa. Twenty patients were included in the final analysis (M/F, 4:1; mean ± SD age, 51.38 ± 6.76 years). Fourteen flaps resembled oral mucosa, 3 had a mixed appearance of both skin and mucosa, and 3 had appearance of normal skin at 1 year follow-up. The epidermis and stratum corneum were retained in all the flap biopsies; however, severe attenuation was noted in 7 patients (had mucosal appearance) but was significantly different from oral mucosa(P = 0.0003). Cutaneous appendages were found in all the flap epithelia. Thirteen flaps showed grossly attenuation, of which 11 patients had a gross appearance resembling oral mucosa and 2 had a mixed appearance. The biopsies showed varied degree of chronic changes like desquamation in around 35% (7 patients), hyperkeratosis in 35% (7 patients), and chronic candidiasis in 30% (6 patients). Although the intraorally transferred flaps demonstrate a morphological appearance similar to oral mucosa, there is a histological preservation of skin elements and architecture.

Facial artery musculomucosal (FAMM) flap

This study presents a thorough overview of the relevant anatomy of this flap, reviews its most common indications, and introduces a step-by-step approach to a successful harvest of the FAMM flap. Knowledge of the surgical anatomy and landmarks of the FAMM flap allows a successful harvest. The superiorly and inferiorly based FAMM flaps are versatile and associated with low morbidity. The indications are numerous in Head & Neck surgery. The most common indications are defects of the floor of mouth, palate, and alveolar ridge. The advantages of this pedicled intraoral flap considerably outweigh its disadvantages. Respect of the steps described herein should allow a successful harvest of the FAMM flap despite potential pitfalls. Refinement of the indications and recent modifications in the technique to lower the revision surgery rates should allow a broader use of this flap.

Combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible following salvage surgery for recurrent head and neck tumours

This study was performed to evaluate the outcomes of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps for the restoration of through-and-through defects of the mandible. The subjects were six patients with recurrent malignant tumours who underwent salvage surgeries and reconstruction with combined flaps based on the transverse cervical vessels (TCVs). All patients had combined bone (four type H, one type LCL, and one type C) and extensive soft tissue defects (through-and-through defects) following salvage surgery. All tumours were removed and the complex defects restored successfully. Two patients experienced minor complications: one minor intraoral flap failure and one case of wound dehiscence at the donor site. The appearance of the face and neck was satisfactory or acceptable in all patients. No patient showed severely limited range of motion of the upper limb. The patients were followed up for 10 to 18months. One patient was living with no evidence of disease. The use of combined bilobed trapezius myocutaneous and scapula osteomyocutaneous flaps based on the TCVs may be an effective approach for the restoration of through-and-through defects of the mandible and may provide satisfactory or acceptable functional and aesthetic outcomes following salvage surgery for advanced head and neck tumours.

The Hairy Cheek: Two Cases of Intraoral Pectoralis Major Myocutaneous Flap Reconstruction

The presence of hairs in the oral cavity is an uncommon phenomenon, despite the frequent use of flaps for reconstruction. An intraoral hairy flap may result in constant discomfort affecting the quality of life of these patients. There are two lines of treatment available – One, by using laser to epilate hair, or second, an inexpensive mean of using scalpel to trim of the hair, which would result only in a temporary relief to the patient. Thus, it is apt to say that it is always preferable to prevent it in the first place than to cure it afterwards. Hereby, we like to highlight two such cases with intraoral hair growth and an alternative technique to negate it which needs to be incorporated in daily practice.

Superiorly based facial artery musculomucosal flap: A versatile pedicled flap.

The superiorly based facial artery musculomucosal (FAMM) flap is pedicled on the angular artery. This flap offers a well-vascularized mucosal surface allowing closure of medium size defects, most frequently within the oral cavity and intranasal region. We describe a superiorly based harvest of the FAMM flap, which may be used for closure of multiple head and neck surgical defects. An operative technique video is provided, which can be viewed online. Our results demonstrate a fast and relatively straightforward harvest technique of the FAMM flap. This intraoral flap is a useful reconstructive tool, which also has the advantage to leave no visible external scars. The superiorly pedicled FAMM flap is a versatile and effective technique that may be integrated in the algorithm for reconstruction of head and neck defects.

Oronasal fistula as a cleft palate sequela : closure with tongue flap. Case report with review of the literature

Introduction: Oronasal fistula have several etiologies. Most of the time, the origin is congenital associated with cleft lip and patate patients, or it can be acquired after trauma, infection, neoplasm, postsurgical complications or radio and chemonecrosis. Excepted for palatal obturators, their treatment is surgical and may use different intraoral flaps. Observation: A 9-year-old girl was sent to consult presenting an oronasal fistula as a sequela of a cleft lip and palate, initially treated in Kosovo (Albania). This was an anterior midpalate fistula, large around 2 cm, functionnaly responsible of a nasal speech and food reflux in the nasal airways. The closure has been done with a tongue flap. Commentary: Most of the oronasal fistulae secondary to a cleft palate are managed with palatal rotational flaps. Nevertheless, they cannot be used in some cases, especially when the fistula size is too large, the localization too anterior and with already scarred palatal tissues around. Then, tongue flap may represent a reliable alternative. Conclusion: The tongue flap allowed a complete closure of the oronasal fistula, with a very good tolerance from the child. It shows its interest into the list of the numerous existing oral flaps. However, considering the discomfort of this technique, it must be done in selected cases, with compliant patients.

A Novel Approach to Improve the Keratinised Peri-Implant Soft Tissues in Patients with Intra-Oral Free Flap Osteocuteanous Reconstruction

A Novel Approach to Improve the Keratinised Peri-Implant Soft Tissues in Patients with Intra-Oral Free Flap Osteocuteanous Reconstruction

Preoperative Laser Depilation Therapy to Address the Hairy Intraoral Flap.

Preoperative Laser Depilation Therapy to Address the Hairy Intraoral Flap.

Sulcular translation flap in secondary bone grafting: retrospective study of 72 alveolar clefts

Secondary bone grafting from the iliac crest is the gold standard in the reconstruction of maxillary alveolar bone defects in cleft patients. Numerous techniques for this graft have been described, although none is considered clearly superior at this time. A retrospective chart study was performed of 72 alveolar clefts in 59 patients who underwent an alveolar iliac crest bone graft with nasal floor reconstruction, with or without concomitant secondary cheilorhinoplasty. Forty-four patients were included in the bone grafting group and 15 in the concomitant cheilorhinoplasty group. Both groups had a sulcular translation mucoperiosteal flap with anterior repositioning of the gingival papilla as the preferred intraoral flap technique. One-third of patients had undergone previous attempts at oronasal fistula closure. Results showed 100% Bergland stage 1 in the cheilorhinoplasty group and 96% in the bone graft group. Two failures (stage 4) were observed in the bone graft group. The infection rate was 9% in the cheilorhinoplasty group and 2% in the bone graft group. Of clefts in the bone graft group, 10% showed postoperative residual fistulas; none were observed in the cheilorhinoplasty group. The sulcular translation flap is a simple surgical approach and shows a low complication rate.