Palatal Mucoperiosteum Research Articles

Lower Eyelid Reconstruction with Mustardé Flap

Restoring defects in the lower eyelids, particularly those that extend beyond two-thirds, can be challenging, especially after tumor resection. Basal cell carcinoma (BCC) is the most common form of skin cancer, affecting the lower eyelid and inner canthus. Grafts are often combined with flaps for replacing the posterior lamella or anterior lamella. The Mustardé rotational cheek flap is a popular choice for reconstructing the anterior lamella of the lower eyelid, as it meets the basic requirements of an ideal cutaneous flap. This wide-based pedicle flap can support free grafts needed to line the inside of the flap. Other autogenous grafts, such as labial mucosa, hard palate mucoperiosteum, auricular cartilage, and nasoseptal cartilage, have also been used in eyelid reconstruction. However, hard palate mucosa transplants provide uniformity and can be expensive. Hughes procedures are not suitable for individuals with amblyogenic age or one-seeking eyes. Combining a vascular flap with a superior graft like pericranium may provide a viable surgical option for enduring functional and aesthetic outcomes.

Palatal Mucoperiosteum-A Redeemable Barrier in Surgical Management of Rhinocerebral Mucormycosis.

Ever since the commencement of the COVID-19 pandemic, post-recovery complications have been in the highlights, out of which rhinocerebral mucormycosis tops the chart. The surgical management of this disease was always aggressive debridement, resection, and antifungal treatment. Oronasal communication after aggressive surgical management always leads to breathing, feeding, and cosmetic impairments. In this study, cases were managed by leaving the palatal mucosa intact after the removal of all the affected hard and soft tissues including the periosteum attached to the mucosa, to preserve the palatal mucoperiosteum and to improve the postoperative complications in patients by maintaining the oronasal separation. Prospective review of the operated case of rhinocerebral mucormycosis in 20 patients was presented. An intraoral approach for hard and soft tissue resection was employed. The palatal mucoperiosteum was salvaged in all patients. Postoperative complications like oronasal communication, ill-fitting prosthesis, and healing were evaluated. A total of 20 patients underwent maxillectomy for mucormycosis involving the maxilla and palate along with other facial bones. The palatal mucosa was preserved and used for oronasal separation. The expected complications of nasal regurgitation, crustation of the maxillary cavity, ill-fitting prosthesis, etc. were evaded due to this. The administration of Inj. liposomal amphotericin B (LiAB) postsurgically has been the backbone of this procedure.

Risk Factors for Failure of Hard Palate Mucoperiosteal Flap Repair of Acquired Oronasal Communication in Dogs: A Pilot Study.

The objective of this retrospective pilot study was to describe potential risk factors for failure of hard palate mucoperiosteal flaps (HPF) transposed for closure of oronasal communication. Dogs (n = 28) with acquired oronasal communication defects were included in the study population. Functional success of an HPF was determined by visual inspection at the last examination and lack of clinical signs. Risk factors for HPF failure including age, sex, body weight, presence of neoplasia at the time of surgery, presence of neoplasia after surgery due to incomplete or narrow margins, use of CO2 laser, previous surgeries in the same location, HPF blood supply, size of the HPF as a percentage of the total area of the hard palate mucoperiosteum, and distance traveled by the apex of the HPF were evaluated using descriptive statistics and unadjusted logistic regression modeling. Seven out of 28 (25%) hard palate flap procedures resulted in persistent oronasal communication and were considered failures. Body weight (Median: 17 vs. 25 kg, OR = 0.94, 80% CI = 0.90, 0.99), presence of neoplasia at the time of surgery (86 vs. 57%, OR = 4.50, 80% CI = 1.01, 20.06), HPF area (Median: 0.49 vs. 0.41, OR = 84.40, 80% CI = 1.66, 4,298) and apex travel distance (Median: 2.06 vs. 0.67, OR = 5.15, 80% CI = 2.14, 12.38) were associated with flap failure. Within this sample, the presence of neoplasia at the time of initial surgery, increasing the area of the HPF, and distance traveled by the HPF apex were associated with a greater odds of HPF failure. Further studies with larger sample sizes are needed to confirm repeatability of these results. HPFs remain a viable surgical option for closure of oronasal communication. Careful surgical planning, strict adherence to surgical principles, and awareness of anatomical limitations can increase the likelihood of success.

Hard Palate Mucoperiosteal Transplantation for Defects of the Upper Eyelid: A Pilot Study and Evaluation.

To use hard palate mucoperiosteum to reconstruct the upper eyelid wisely and to evaluate its function and outcome. In this case series, medial or lateral defects of the upper eyelid were reconstructed with a hard palate mucoperiosteum graft and a bandage contact lens to protect the cornea. Slit-lamp examinations, in vivo confocal microscopy, patient surveys, and pathologic examinations were performed as evaluations. Seven patients were included in this study. The average follow-up time was 21.9 months. Postoperatively, all patients maintained their preoperative corneal transparency, and the best-corrected visual acuities remained stable. Postoperative corneal examination by in vivo confocal microscopy was similar to the normal contralateral eye in all cases. All hard palate mucoperiosteal grafts merged smoothly with the normal tarsoconjunctiva. The mean ratio of the graft length to the upper eyelid decreased from 48.6% during the operation to 32.2% during the follow-up; the average shrinkage rate was 16.3% ± 7.1%. Both in vivo confocal microscopy and the pathologic examinations showed that stratified squamous epithelium comprised the main part of the hard palate graft. All patients could blink normally and had a relatively normal appearance. All patients were satisfied with the overall outcome of this therapy. Main complications included loss of eyelashes (100%), abnormal curvature of the eyelid (28.5%), mild lagophthalmos (14.3%), trichiasis (14.3%), and slight exfoliation of the corneal epithelium (42.8%). not only effectively reconstructs the upper eyelid but also provides protection for the cornea.

Cleft Palate Repair without Lateral Relaxing Incision.

Background:The goals of successful palate repair include optimization of speech and feeding, avoidance of fistula formation, and mitigation of adverse maxillary growth. However, the effects of scar formation on maxillary growth have not been discussed in detail.Methods:Between November 2010 and December 2011, the palateplasty was performed for 24 patients with cleft palate (median age, 12 months; range, 11–18 months). In the velum, a symmetrical intravelar veloplasty with mucosal Z-plasty was performed on both the nasal and oral sides. In the hard palate, instead of lateral relaxing incisions, a 1-line mucoperiosteal incision along the cleft margins was designed with subperiosteal undermining in the entire palatine bone. The palatal mucoperiosteum was sutured together in the middle of the cleft, and the cleft was directly closed without lateral relaxing incisions. The patients were monitored for 6 months to 1.6 years.Results:None of the cases had issues concerning flap viability, and all palate repairs healed well. Postoperative results were satisfactory, without any complications such as dehiscence, perforation, or palatal fistula.Conclusions:The method presented in this article was effective, with successful palatal closure and without scar formation or mucosal defects along the alveolus. We conclude that minimum contracture of the hard palate was useful for not only mitigating adverse maxillary growth but also for orthodontics.

Novel use of a resorbable sheet in combination with a vomerine flap in cleft palate reconstruction

Background and objectives: Many techniques are available to repair clefts of the palate. Techniques involving substantial stripping of the palatal mucoperiosteum, lead to maxillary hypoplasia. Vomerine flaps have been proven to be less detrimental to maxillary growth; however, they are technique sensitive. Cranially-based vomerine flaps are easier to create than caudally-based flaps, especially in narrower clefts, but a palatal groove formation often occurs upon healing. Maintenance of the blood-clot in the exposed flap bed would prevent this phenomenon.

Preservation of palatal mucoperiosteum for oronasal separation after total maxillectomy

Oronasal communication occurs after total maxillectomy for advanced sinonasal cancers. This results in feeding, breathing and cosmetic impairment. Various methods have been described to close off the palatal defect from the oral cavity to improve the function of speech and deglutition. The object of this article is to describe our experience of preservation of palatal mucoperiosteum for oronasal separation. Retrospective review of clinical and operative records of 31 total maxillectomy patients where oronasal separation was achieved by the conventional technique of applying a maxillary obturator. The postoperative complications arising from the use of maxillary obturator for oronasal communication after total maxillectomy in these 31 patients were analysed. To avoid the complications encountered in these 31 patients we preserved and used the ipsilateral palatal mucoperiosteum for oronasal separation. This new technique was applied in 12 patients. The results are presented and compared. A total of 43 patients underwent total maxillectomy for advanced sinonasal tumors. In 31 patients the conventional maxillary obturator was used for oronasal separation. Among these patients, 30 had crustation of the maxillary cavity, nasal regurgitation and cheek skin retraction in 15 each, trismus in eight, infection of skin graft donor site in seven, cheek movement during respiration in five and ill-fitting prosthesis in three. In 12 patients palatal mucoperiosteum was preserved and used for oronasal separation. The complications encountered in oronasal separation by palatal prosthesis were avoided in the modified procedure. We found that oronasal separation by preservation of palatal mucoperiosteum following total maxillectomy allowed excellent palatal function, prompt rehabilitation and minimal complications without compromising the prognosis.

Transpalatal approach with pedicled palatal osteo-muco-periosteal flap

In the conventional technique of transpalatal approach, the palatal mucoperiosteum is incised and widely elevated and hard palate bone is removed in piece meal and discarded. These technique lead to complications, namely, temporary or permanent palatal fistula, palatal scarring leading to palatal disfiguration and velopharyngeal incompetence. In this article we describe a new technique of doing palatotomy to avoid these complications. A retrospective review of post-operative complications of 20 patients that underwent transpalatal approach by the conventional technique was performed. To avoid the complications encountered in these cases, a new approach was designed when the palatal mucoperiosteum on the pathological side was elevated partially, greater palatine artery was coagulated and palatal osteotomy was performed from the oral side. On the non-pathological side, hard palate was sectioned from the nasal side, thus preserving the ipsilateral palatal mucoperiosteum. The entire mucoperiosteum with attached hard palate was reflected orally as a single block which was pedicled on the greater palatine artery and palatal mucoperiosteum of the non-pathological side, thereby creating palatal osteo-mucoperiosteal flap. The flap was placed back at the end of the procedure. Eight patients were operated by this new technique. All 20 patients operated by the conventional transpalatal approach developed post-operative complications. In the eight patients operated by the new technique, no post-operative complications were encountered after 2 years' follow-up. We found palatal osteo-mucoperiosteal flap an easy and safe way of preserving the hard palate mucoperiosteum and bone with its vasculature resulting in quicker healing and minimal functional impairment.

Fermeture des fistules palatines séquellaires de fentes

Treatment of oronasal fistulae in cleft patients remains a surgical challenge because of its high failure rate. The authors report the results of an aggressive surgical technique using the total elevation of palatal mucoperiosteum, even for small fistulae. This approach was used on twelve consecutive patients, from five to 33 years of age, presenting with a Pittsburgh classification type IV palatal fistulae. The surgical procedure was total elevation of the hard palate mucoperiosteum starting from the dental sulcus combined with sealed double layer sutures. Clinical and photographical control was made at least 6 months after to detect a possible relapse. The success rate was 100%. No relapsing fistula was observed with follow-up ranging from 6 to 36 months. This technique allows wide exposure and safe closure of the nasal layer. It is simple and leaves no raw bone surface exposed and no additional scar. The authors think it can be used in all type IV fistulae less than 1cm wide. Several other surgical techniques have been described to close palatal fistulae: local turnover flaps, pedicled flaps from adjacent oral tissue, tongue flaps, tissue expansion, and even free flaps. Obturator prostheses have also been used. The technique we report, even if more aggressive, seems to be more reliable with fewer relapse and sequelae.

Novel Use of Osmotic Tissue Expanders to Treat Difficult Anterior Palatal Fistulas

Novel use of osmotic tissue expanders to recruit local palatal mucoperiosteum for the treatment of difficult anterior palatal fistulas. This is a retrospective review of our experience with osmotic tissue expanders for closure of secondary palatal fistulas. The study occurred at Oregon Health and Science University, a tertiary care level academic hospital. All patients were treated for combined cleft lip and palate by the Oregon Health and Science University Craniofacial Disorders multidisciplinary team. They were determined to be appropriate candidates due to the anterior location of the fistula and symptomatic nature. Patients complained of significant nasal regurgitation of liquid and solids. All patients underwent a two-stage procedure under general anesthesia. The first stage was placement of the expanders. The second stage was 1 week later, with removal of the expanders, palatal revision, and closure of the oronasal fistula. The primary outcome measures determined before data collection were treatment of symptoms and decreased size of fistula. Seven patients with palatal fistulas were treated with osmotic tissue expanders. Five patients had complete closure of the fistula. Two patients demonstrated slit-like fistulas that were no longer symptomatic and were amenable to closure at time of alveolar bone grafting. No complications were observed. The use of osmotic tissue expanders is a viable alternative for repair of large anterior palatal fistulas, especially in a scarred or previously operated palate. Patients were also no longer symptomatic.

Bipedicle mucoperiosteal flap repair of postpalatoplasty fistula: Can it reduce postoperative recurrence?

Palatal fistula following repair of cleft palate is a challenging problem and its repair is technically difficult. Many surgical techniques were described for management of postpalatoplasty fistula. Twenty eight patients with postpalatoplasty fistulas were repaired with Bipedicled mucoperiosteal flap with only 2 cases of recurrent fistulas (7.2%). Bipedicle mucoperiosteal flap utilizing the whole palatal mucoperiosteum is a reliable technique for repair of postpalatoplasty fistulas with a high success rate.

Bone marrow‐derived cells in palatal wound healing

Myofibroblasts are responsible for contraction and scarring after cleft palate repair. This leads to growth disturbances in the upper jaw. We hypothesized that cells from the bone marrow are recruited to palatal wounds and differentiate into myofibroblasts. We transplanted bone marrow from green fluorescent protein (GFP)-transgenic rats into lethally irradiated wild-type rats. After recovery, experimental wounds were made in the palatal mucoperiosteum, and harvested 2 weeks later. GFP-expressing cells were identified using immunostaining. Myofibroblasts, activated fibroblasts, endothelial cells, and myeloid cells were quantified with specific markers. After transplantation, 89 ± 8.9% of mononuclear cells in the blood expressed the GFP and about 50% of adherent cells in the bone marrow. Tissue obtained during initial wounding contained only minor numbers of GFP-positive cells, like adjacent control tissue. Following wound healing, 8.1 ± 5.1% of all cells in the wound area were positive, and 5.0 ± 4.0% of the myofibroblasts, which was significantly higher than in adjacent tissue. Similar percentages were found for activated fibroblasts and endothelial cells, but for myeloid cells it was considerably higher (22 ± 9%). Bone marrow-derived cells contribute to palatal wound healing, but are not the main source of myofibroblasts. In small wounds, the local precursor cells are probably sufficient to replenish the defect.

Palatal Flap Modifications Allow Pedicled Reconstruction of the Skull Base

Defects after endoscopic expanded endonasal approaches (EEA) to the skull base, have exposed limitations of traditional reconstructive techniques. The ability to adequately reconstruct these defects has lagged behind the ability to approach/resect lesions at the skull base. The posteriorly pedicled nasoseptal flap is our primary reconstructive option; however, prior surgery or tumors can preclude its use. We focused on the branches of the internal maxillary artery, to develop novel pedicled flaps, to facilitate the reconstruction of defects encountered after skull base expanded endonasal approaches. Feasibility. We reviewed radiology images with attention to the pterygopalatine fossa and the descending palatine vessels (DPV), which supply the palate. Using cadaver dissections, we investigated the feasibility of transposing the standard mucoperiosteal palatal flap into the nasal cavity and mobilizing the DPV for pedicled skull base reconstruction. We transposed the palate mucoperiosteum into the nasal cavity through limited enlargement of a single greater palatine foramen. Our method preserves the integrity of the nasal floor mucosa, and mobilizes the DPV from the greater palatine foramen to their origin in the pterygopalatine fossa. Radiological measurements and cadevaric dissections suggest that the transposed, pedicled palatal flap (the Oliver pedicled palatal flap) could be used to reconstruct defects of the planum, sella, and clivus. Our novel modifications to the island palatal flap yield a large (12-18 cm(2)) mucoperiosteal flap based on a approximately 3 cm pedicle. The Oliver pedicled palatal flap shows potential for nasal cavity and skull base reconstruction (see video, available online only).

Effects of bFGF on suppression of collagen type I accumulation and scar tissue formation during wound healing after mucoperiosteal denudation of rat palate

Objective. The purpose of this study was to evaluate the effect of basic fibroblast growth factor (bFGF) on collagen changes after mucoperiosteal denudation of rat palate. Material and methods. A total of 36 male Wistar rats were divided into control, scar, sham, and bFGF groups. In the scar, sham, and bFGF groups, lateral palatal mucoperiosteum was excised to form scar tissue on the palate. In the bFGF group, bFGF solution was injected into the operated area 1 week postoperatively. At 6 weeks postoperatively, the distribution of collagen type I and the 3-dimensional structure of collagen fibers were investigated under immunofluorescent and scanning electron microscopy. Result. In the bFGF group, weakly immunostained submucosa was clearly distinguishable from the strongly immunostained cervical periodontal ligament and gingiva. Collagen fibers running from submucosal tissue into the surface of underlying palatal bone comprised loosely arranged collagen fibrils. Lumen structures in collagen fibers resembled those in the control group. Conclusion. Administration of bFGF for suppression of collagen type I generation could suppress scar tissue formation and reduce connective strength with adjacent teeth and palatal bone.

Evaluation of a Collagen-Glycosaminoglycan Dermal Substitute in the Dog Palate

Tissue shortage complicates surgery of cleft lip and palate. The healing of defects on the palate impairs growth of the dentoalveolar complex because of scar tissue formation. Implantation of a matrix into the wound might overcome this adverse effect. Integra with and without a silicone top layer was implanted into standardized full-thickness wounds (Ø 6 mm) in the palatal mucoperiosteum in beagle dogs. In some wounds, the silicone layer was removed after 14 days. Control wounds did not have an implant. At 2 and 4 weeks post-surgery, the wounds were assessed for epithelialization, inflammation (hematoxylin and eosin, leucocyte protein L1), number of myofibroblasts (alpha smooth muscle actin), and general histological characteristics. Wounds filled with Integra without the silicone layer showed fewer myofibroblasts and inflammatory cells than the sham wounds. Collagen fibers were more randomly orientated in these wounds than in the sham group. Wound closure was found to be retarded, and many inflammatory cells were present when Integra with silicone was implanted. The silicone layer was lost within 4 weeks in these wounds. We conclude that, in the moist oral environment, the silicone of Integra is not required. Re-epithelialization and tissue integration proceed more favorably without it. Further research in the dentoalveolar development with Integra will be conducted in a simulated cleft palate repair in the dog model.

Treatment modalities for closure of palatal fistulae

Background: Surgical correction of a cleft palate provides a myriad of problems to the operating surgeon. The aim to achieve this closure and to restore normal velar function is hampered by a palatal fistula. The repair of a palatal fistula in the cleft palate patient presents a new challenge and various techniques for their correction have been proposed. Local transposition flaps may be successful, but repeated failure can occur due to the thick and immobile scarred palatal mucoperiosteum. A variety of both surgical and prosthetic solution to the problem of inadequate local tissue has been sought.

Hard Palate Mucoperiosteal Graft for Posterior Lamellar Reconstruction of the Upper Eyelid

Reconstruction of full-thickness upper eyelid defects often requires repair of both the anterior lamella (skin and orbicularis oculis muscle) and the posterior lamella (tarsus and conjunctiva). Various autogenous grafts have been used for posterior lamellar reconstruction, but it is still unclear which material is most suitable for repairing the posterior lamella. We report a patient in whom a subtotal defect of upper eyelid was reconstructed with a bipedicled myocutaneous flap lined by hard palate mucoperiosteum. We also examined tarsoconjunctiva, labial mucosa, hard palate mucoperiosteum, and auricular cartilage histologically and assessed the histologic features of these tissues as substitutes for the posterior lamella. An even and stable upper eyelid was formed by our method of reconstruction. A mucoperiosteal graft from the hard palate bears a close resemblance to the tarsoconjunctiva histologically because it contains both fibrous connective tissue and a mucous membrane. The graft took completely and there was no donor site morbidity or postoperative complications. A hard palate mucoperiosteal graft may be an optimal substitute for the posterior lamella of the upper eyelid.

Roles of Different Areas of Palatine Bone Denudation on Growth and Development of the Maxilla and Dental Arch

This study was designed to explore the relationship of the growth of the maxilla and dental arch with different sizes of the denudation area on the hard palate. We tested the hypothesis that different sizes of denudation areas on the hard palate following palatoplasty would significantly influence the growth of the maxilla and dental arch differently. Fifty-one three-week-old Sprague-Dawley male rats were randomly divided into a control group and 3 experimental groups. In the three experimental groups, bilateral palatal mucoperiosteum was excised to three different proportions, i.e. one-quarter, one-half and three-quarters of the palate. Then, the animals were sequentially injected weekly with different fluorescent markers alternately. Three in each group were sacrificed randomly every two weeks with maxilla dissected following injections. The widths of the maxilla and dental arch were measured and the fluorescent labeling investigated at different phases. The results showed that the growth of the maxilla and dental arch here was inversely correlated with the area of denuded bone on palate. Therefore, our data may provide references for optimal treatment of cleft palate.

In Vitro Manipulation of Cleft Palate Connective Tissue: Setting the Bases of a Proposed New Treatment

Palatoplasty has the undesired side effect of impaired mid-facial growth. To avoid this problem, we propose an alternative to palatoplasty. We hypothesize that if BMP-2 is injected together with a carrier into the periosteum of the cleft palate borders, border volume will increase and connective tissue cells will be activated to produce extra bone. Once these borders supported by bone reach the midline, extraction of their covering epithelia with trypsin will permit adhesion of the underlying tissues. We investigated in vitro the ability of cleft palate connective tissue cells to produce extra bone in the presence of BMP-2 and the possibility of using trypsin to remove the epithelium covering the cleft palate borders without impairing the underlying tissues' ability to adhere. We used the cleft palate presented by tgf-beta(3) null mice and small fragments of human cleft palate mucoperiosteum as models. Immunolabeling BMP-2-treated or untreated cultures with TUNEL and anti-osteocalcin or PCNA antibodies was performed. The epithelium of the cleft palate borders was removed with a trypsin solution, and the de-epithelialized tissues were cultured in apposition. BMP-2 induces differentiation toward bone on cleft palate connective tissue cells without producing cell death or proliferation. Trypsin removal of the cleft palate margins' epithelium does not impair the underlying tissues' adhesion. It is possible to generate extra bone at the cleft palate margins and to chemically eliminate their covering epithelia without damaging the underlying tissues, which allows further investigation in vivo of this new approach for cleft palate closure.

Effects of locally injected interferon-beta on palatal mucoperiosteal wound healing.

Wound contraction and scar formation in the palatal mucoperiosteum after cleft palate surgery impair maxillary growth. The aim of this study was to determine the effects of IFN-beta on palatal mucoperiosteal wound healing in growing rats. Standardized wounds were made in the palatal mucoperiosteum of young rats. Either IFN-beta or vehicle were injected at the wound site between 4 and 29 days after wounding. The results were compared with control wounds. Tissue samples were collected at 8, 15, 30, and 60 days PW for biochemical and microscopic analysis. IFN-beta stimulated re-epithelialization but did not reduce the number of myofibroblasts or scar tissue formation. Surprisingly, the injection of vehicle alone delayed the healing process. IFN-beta might be suitable to stimulate re-epithelialization but it does not reduce scar tissue formation in rat palatal wound healing. The injection of agents into palatal wounds might severely impair the healing process.