Abstract
Functional reconstruction of a combined upper lip and palatal defect presents surgical challenges that differ from either type of defect in isolation. While useful in obtaining tissue coverage for large defects, free flaps lack the ability to re-establish oral muscular function. Further, local or regional flaps are limited by the amount of adjacent tissue that can be recruited without causing excessive deformity. We present a case of an 81-year-old female with a history of recurrent verrucous carcinoma of the anterior maxillary vestibule. The patient underwent wide local excision, resulting in a large hard palate and alveolar defect combined with a complex upper lip defect. A modified Karapandzic flap with bilateral peri-alar extensions and a fasciocutaneous radial forearm free flap were used to restore oral function and close the palatal defect, respectively. In our case, this combined approach allowed for aesthetic reconstruction of the upper lip and functional closure of a large oral nasal fistula. At one year, the patient demonstrates a healthy palatal flap with closure of the oronasal fistula and a competent oral sphincter.
Highlights
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Complex maxillary defects require multimodal approaches.
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Combined local and free flaps are effective in solving complex reconstructive challenges.
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The first reported cadaveric anatomic basis of the Karapandzic flap is provided in this manuscript.
1
Introduction
In 1974, Miodrag Karapandzic described a local arterial flap for reconstruction of lower lip defects [ ]. The technique is based off the facial artery and labial branches. The paired flap incisions are designed to parallel the lip margin at an equal distance to the depth of the defect. This technique, known now as the Karapandzic flap, provides satisfactory functional and aesthetic results for lip reconstruction. 2 When the technique is applied for upper lip reconstruction, preservation of the arterial and neural supply to the flaps requires careful dissection superficial to the orbicularis oris muscle near the insertion of the lip elevators. In addition, greater mobility of the flaps can be obtained by releasing the lip elevators from the orbicularis muscle.
The radial forearm free flap (RFFF), originally described by Yang in 1981, has proved useful for the reconstruction of palatal defects following maxillectomy [ ]. The RFFF provides abundant, pliable tissue for palatal reconstruction and ample pedicle length for anastomosis. During inset, the flap may be deepithelialized at the margins to substantially decrease the risk of fistula formation [ ]. The palmaris longus tendon can also be included with the RFFF to aid in suspension of the levator and pharyngeal constrictor to improve functional outcomes in cases of soft palate involvement [ ].
An alternative approach to managing a palatal defect is the use of an obturator. Obturators have been shown to provide adequate functional results when the defect is less than 50% of the palate and does not include the anterior palate from canine to canine. The advantages of an obturator are shorter treatment time, no additional hospital stay, and the ability to examine the maxillectomy cavity for disease surveillance. Limitations of obturators include interference with hygiene, need for repeated adjustments, instability and displacement during mastication or speech [ ].
Free flap reconstruction may provide for better functional outcomes than obturation when the palatal defect is large [ , ]. Objective comparisons for quality of life after free flap closure or obturation are difficult to achieve, as patients and defects are unique. The available research on this topic is lacking in quality, partly due to heterogeneous methodology in published studies [ ]. When comparing the quality of life between a free flap and an obturator for reconstruction of palatal defects one study demonstrated no statistical difference [ ].
The Karapandzic flap is commonly used to address composite defects of the lower and upper lip. However, few studies have investigated the anatomical basis for the flap. In our case report and cadaveric dissection, we emphasize the importance of separating the lip elevating musculature from the oral sphincter closing muscles to reduce tension on the orbicularis oris muscle. In addition, we demonstrate the feasibility of combing this technique with a soft tissue free flap for reconstruction of a complex orofacial defect.
2
Case report
An 82-year-old female diagnosed with verrucous carcinoma of the anterior maxilla presented for reconstruction after partial maxillectomy and three prior unsuccessful attempts at soft tissue closure of defect. The defect included the philtral subunit, left lateral subunit of the upper lip, the anterior maxillary alveolar ridge from the right canine to the left second premolar, and greater than 50% of the hard palate ( Image 1 ). Initial treatment included primary lip closure and a palatal obturator. The obturator was functional for ten days postoperatively. The lip closure dehisced during the second postoperative week, resulting in a wide cleft lip deformity in continuity with the anterior maxillectomy defect ( Image 2,3 ). Two subsequent attempts at primary closure were unsuccessful. In addition to the obvious detriment to the patient’s physical appearance, the defect interfered with the function of the obturator, caused difficulty with eating, and negatively affected the patient’s quality of life.
Due to the size and complexity of the defect, a combined approach using free tissue transfer with local tissue rearrangement was recommended. A modified Karapandzic flap was chosen to reconstruct the upper lip defect. Due to the patient’s frailty, history of peripheral vascular disease and the increased morbidity with osteocutaneous flaps, a fasciocutaneous radial forearm free flap was chosen to close the palatal defect and provide support to the lip ( Images 4,5,6,7 ).
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