An illustration of the overall procedure. The squamous temporal bone has been drilled away and the pterygoid plates released from the sphenoid bone (A). Areas where bone removal will be continued to fully expose the maxillary division of the trigeminal nerve and to remove tumor have been marked (B, hash-marked bone). The zygoma is temporarily removed and the palate resected, while the temporalis muscle and its vascular supply are preserved. The entire temporalis muscle can be rotated into the defect, or only a portion of it (C). The flap is secured with sutures and the zygoma replaced (D).
Intraoperative view of patient 8 showing the mass on the left hard palate around the greater and lesser palatine foramina (A). The tumor is removed through the mouth, leaving a 30% defect of the left hard palate extending on to the soft palate (B).
Intraoperative view of patient 8 showing the temporalis fossa after the temporalis muscle (arrow) has been rotated in to fill the tissue defect (A). The intraoral view after securing the flap shows the excess amount of tissue used to allow for eventual contraction (B).
Patient 13. A sizable defect (A) is reconstructed with the temporalis muscle, showing the amount needed to overfill the defect (B). The flap subsequently undergoes mucosalization and at 3 weeks postoperatively (C) is nearly completely covered with mucosa. Over time, approximately 50% of the original volume is lost, as shown at a 6-month follow-up (D).
Postoperative view of patient 8 taken 8 months after the procedure. A porous polyethylene implant has been used to recontour the temporalis fossa (A). The temporalis flap completely mucosalizes, forms a tight seal between the nose and mouth, and incorporates into a functioning soft palate preventing velopharyngeal insufficiency (B).
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Browne JD, Holland BW. Combined Intraoral and Lateral Temporal Approach for Palatal Malignancies With Temporalis Muscle Reconstruction. Arch Otolaryngol Head Neck Surg. 2002;128(5):531–537. doi:10.1001/archotol.128.5.531
To evaluate the use of a combined lateral temporal fossa and intraoral approach to resect palatal carcinomas and the use of a temporalis myofascial flap for reconstruction.
Retrospective chart review of a case series.
Tertiary university referral hospital.
Sixteen patients underwent a combined approach for resection of palatal carcinoma; 5 of the 16 were edentulous. Six types of tumors were treated: adenoid cystic carcinoma (3 patients), low-grade mucoepidermoid carcinoma (5 patients), squamous cell carcinoma (3 patients), polymorphous low-grade adenocarcinoma (2 patients), osteosarcoma (1 patient), ameloblastoma (1 patient), and hyalinizing clear cell carcinoma (1 patient).
Main Outcome Measures
The postoperative diet, velum competence, flap viability, complications, and survival.
Fifteen (94%) of 16 patients were able to resume their preoperative diets. No velopharyngeal insufficiency was encountered. All flaps survived and none required repeated surgical intervention. Five patients developed serous otitis media and 2 patients required flap revision secondary to posterior choanal obstruction. One patient died of complications unrelated to the procedure.
A combined intraoral and lateral temporal fossa approach allows for (1) en bloc resection of palatal malignancies along with resection of involved pterygoid muscles, (2) isolation and resection of descending palatine nerves and the proximal second division of the trigeminal nerve, and (3) primary reconstruction of the palatal defect by means of the temporalis muscle rotated into the operative defect. This method is especially useful in treating patients with perineural spread of palatal carcinoma, and in those who are edentulous.
PALATAL CARCINOMA presents challenges to the head and neck surgeon in terms of resection as well as defect reconstruction. Such tumors can grow into the maxillary sinus, inferior orbital structures, and skin of the cheek, as well as extend into skull base structures. Carcinomas of minor salivary gland origin, as well as squamous cell carcinomas, have been shown to spread perineurally along cranial nerves up to the skull base and through cranial foramina.1-3 In such instances of nerve involvement, the maxillary division of the trigeminal nerve (cranial nerve division V2), including the greater and lesser palatine nerves, is most frequently affected. Tumor can extend along the descending palatine nerve into the pterygopalatine fossa (PPF) and ultimately through the foramen rotundum.4,5 En bloc resection of palatal malignancies with perineural spread ideally must use an approach that allows for dissection of the descending palatine nerves into the PPF and skull base.
There are numerous methods of resecting palatal malignancies. Facial degloving approaches have been used extensively for access to these tumors. More extensive tumors that grow into the maxillary sinus can require a subtotal maxillectomy for en bloc removal. These are typically approached through facial-splitting incisions such as the Weber-Furguson incision or modifications thereof. Approaches to the PPF specifically include an extended Weber-Furguson incision6 and transcervical transmandibular dissection,7 both of which incur a significant morbidity encountered with transfacial approaches. A previously described preauricular transzygomatic infratemporal fossa (subtemporal) approach8-10 is useful in resecting the perineural growth extensions of the tumor; however, this approach alone does not easily allow for en bloc resection of the primary palatal tumor itself.
A variety of methods have been used to reconstruct the defect created after removal of the hard and/or soft palate. Prosthetic obturators have been used with success for defects that involve both the hard and soft palate.11,12 However, obtaining the proper fit and seal with these prosthetics can be difficult for large defects in edentulous patients, and many patients have transportation issues that limit access to prosthedontic rehabilitation. Numerous surgical modalities for primary reconstruction have been described. Regional flaps used to reconstruct the palate include the temporalis myofascial flap,13-16 a nasal septal flap,17 an infrahyoid myocutaneous flap,18 and a pectoralis major myocutaneous flap.19 Vascularized free tissue transfer flaps have also been used to reconstruct larger defects, especially those that involve the orbit and/or facial skin.20-22 Ideally, primary reconstruction of the defect would obviate the need for a prosthesis, have low or no donor site morbidity, and produce a functionally and cosmetically pleasing result.
We report a procedure for resection of palatal malignancies that uses a combined intraoral and lateral temporal fossa approach to remove the primary tumor, resect tumor spreading perineurally to the skull base within the PPF, and reconstruct the tissue defect with a temporalis muscle rotational flap. The surgical technique is described herein, as well as the pathologic findings, clinical history and course, and outcome of 16 patients treated at our institution for palatal malignancy.
Patients selected for this retrospective review were those with palatal or maxillary malignancy that did not involve the orbital floor or orbit. Preoperative contrast-enhanced computed tomographic scanning and magnetic resonance imaging were performed in each patient to evaluate perineural extension of the tumor and possible involvement of the skull base. All patients were treated by one of us (J.D.B.) at North Carolina Baptist Hospital, Winston-Salem, a tertiary university hospital associated with the Wake Forest University School of Medicine's Department of Otolaryngology–Head and Neck Surgery. Informed consent was obtained in accordance with an approved human subjects protocol. A chart review of these patients was performed in October 2000, and data were collected regarding recurrence, length of follow-up, postoperative diet, velopharyngeal insufficiency, survival, and complications.
Illustrations that summarize the surgical technique are shown in Figure 1. The temporalis muscle and PPF–skull base are approached through a curvilinear, pretragal incision that is extended superiorly within the hairline. Electrocautery is used to elevate the skin flap anteriorly to the zygomatic arch. The frontal branch of the facial nerve is preserved by directly elevating it off the zygoma with the adjacent soft tissue and periosteum. A miniplate is predrilled in the areas of the temporal process of the zygoma and the posterior zygomatic process in preparation for replacement at the end of the procedure. After removal of the arch, the temporalis muscle is elevated off its superior insertion and elevation progresses inferiorly. Electrocautery is used to perform this subperiosteal elevation of the temporalis muscle off of the squamous temporal bone. The attachment of the muscle to the coronoid process is preserved. The blood supply to the flap is the anterior and posterior deep temporal arteries, which are branches of the maxillary artery.13,15 The vascular supply on the undersurface of the flap is preserved. This results in exposure of the greater wing of the sphenoid, orbital apex, and bone overlying the middle fossa dura.
Bone removal is continued to the root of the lateral pterygoid plate. The pterygoid muscles are elevated from their anterior and lateral attachments, and the pterygoid plates are drilled free and released from the sphenoid bone. If necessary, a small craniectomy is performed at the base of the temporal horn, posterior to the orbital apex, to allow full visualization of the maxillary division of the trigeminal nerve to the level of the gasserian ganglion with gentle extradural dissection. Resection of the involved division of the trigeminal nerve (cranial nerve division V2in this instance) is then possible, depending on the extent of tumor spread (Figure 1A).
The patient's mouth is opened and mucosal incisions are made along the hard palate, alveolar ridge, gingivobuccal sulcus, and soft palate. Osteotomies are made through the palate and into the maxillary sinus. Care is taken not to disrupt the floor of the orbit. The deep attachments are released intraorally and through the temporal approach. The entire tumor mass and hard palate are then removed en bloc through the mouth (Figure 2B).
The temporalis muscle is then used to reconstruct the oral cavity. The entire muscle or only the anterior portion is rotated into the infratemporal region, depending on the size of the palatal defect (Figure 3A). Deep sutures are used to secure the flap, and resorbable sutures are placed intraorally to oppose the flap and the remaining palatal mucosa (Figure 3B). The temporal incision is irrigated, and the zygoma is resecured into its original position with miniplates. Any remaining posterior temporalis muscle is secured to the lateral orbital rim to fill the temporal fossa. The temporalis fossa can be recontoured with a porous polyethylene implant (Porex Surgical, Inc, College Park, Ga) inserted at the time of resection if desired. The scalp incision is closed. Suction drains are not used.
Sixteen patients were treated between August 1, 1994, and October 31, 2000. Four patients were women and 12 were men. Their ages ranged from 21 to 83 years, with an average age of 56 years. Three patients had adenoid cystic carcinoma, 5 had low-grade mucoepidermoid carcinoma, 3 had squamous cell carcinoma, 2 had low-grade adenocarcinoma, and 1 patient each had osteosarcoma, hyalizing clear cell carcinoma, and ameloblastoma. Table 1 summarizes the demographic and diagnostic information on these 16 patients. The follow-up ranged from 9 months to 7 years, with a mean follow-up of 31 months and a median of 24 months.
The amount of palate resected in this series varied from 25% to 100%, but most had 30% to 50% removed. Patient 10 represents a special case in which the entire palate was removed. This patient had a hyalinizing clear cell carcinoma of the hard palate that did not respond to extensive radiation. He had bilateral perineural extension of the tumor, and a total palatectomy was performed with dissection up to the skull base on each side. To reconstruct this defect, bilateral temporalis muscle flaps were rotated in to create an entire neopalate. To facilitate healing, a split-thickness skin graft was placed over the temporalis muscle. His postoperative diet differed from his preoperative diet in that after surgery he subsisted on pureed foods. This patient had nasal obstruction after surgery but no velopharyngeal insufficiency. Because nasal stenting produced transient velopharyngeal insufficiency in this patient, he chose to tolerate the nasal obstruction and alleviate nasal regurgitation. We believed any procedure to open his nasal passage might produce velopharyngeal insufficiency, and because the patient was not markedly concerned about his nasal obstruction, he desired no further treatment.
All the flaps in this series survived, and none required postoperative intervention to maintain flap viability. In the absence of radiation, no skin grafting was necessary to cover the myofascial temporalis flap, as the entire flap remucosalized within 3 to 4 weeks of surgery. Patients were typically allowed to start oral intake of fluids on postoperative day 2. The flap did experience volume reduction of approximately 50% with time; this needed to be taken into account when we decided how much of the temporalis muscle to rotate into the defect (Figure 4). A typical postoperative result is shown in Figure 5. Three patients in this series had perineural extension of tumor up into the PPF along the descending palatine nerves. These 3 all had adenoid cystic carcinoma, and all 3 received postoperative radiation therapy. Postoperative radiation did not appear to affect the degree of mucosalization of the flap, nor the amount of flap volume reduction in this series.
The diet of each patient was examined before and after the surgical procedure. Fifteen (94%) of the 16 were able to resume their preoperative diets. Eleven of the 16 patients were able to eat a regular diet without limitation. The other 5 were edentulous; of these, 2 ate the same diet they did before surgery with the use of a denture plate, and 2 others tolerated a soft diet and were candidates for denture plates but had no plans to obtain a denture plate. No patient experienced velopharyngeal insufficiency while speaking or nasal regurgitation with eating or drinking.
The complications of this procedure related to the flap bulk in the nasopharnyx, which, if sufficiently large, can have obstructive effects. Five patients developed serous otitis media in the ipsilateral ear requiring tympanostomy tube insertion. However, 4 of these 5 had radiation therapy to the operative site, which may have had some negative impact on the eustachian tube function in these patients. Three patients experienced nasal obstruction because of the temporalis flap obstructing the posterior choana. Patient 1 had mild obstruction, which was successfully treated with a single carbon dioxide laser debulking of the flap in the posterior choana. Patient 4 developed complete posterior choanal stenosis and nasal obstruction, and this was treated with carbon dioxide laser debulking of the temporalis flap and placement of a split-thickness skin graft in the posterior nasal cavity and nasopharynx. The success of this procedure could not be determined because the patient subsequently died of osteoradionecrosis of the pons, which developed after she underwent radiation therapy at another institution. This was the only death to date in this series.
Tumors with perineural extension and/or involvement of a large surface area of palate may present a difficult problem in terms of access and availability of tissue for reconstruction. Facial-splitting incisions such as the Weber-Furguson incision allow for wide exposure, but visualization of the PPF can still be limited, and cosmesis is not ideal. Facial degloving approaches have better cosmesis but limited exposure. Our lateral approach most closely resembles a previously described technique10 but differs in the extent of lateral exposure, ours being limited to cranial nerve division V2 in the PPF. A combined approach illustrated in our series allows for excellent exposure of the deep perineural invasion of these tumors, resection of involved pterygoid muscles, and en bloc resection of the primary tumor bulk. Furthermore, it allows a double vantage point, from which one can perform difficult deep dissections using one approach while viewing from the other.
Many different methods have been proposed for reconstructing these defects, which include a prosthetic obturator,11,12 temporalis myofascial flap,13-16 infrahyoid myocutaneous flap,18 and pectoralis myocutaneous flap.19 Myocutaneous free flaps, with or without an osseous component, have also been described to reconstruct the palate.20 Davison et al21 proposed an algorithm for maxillectomy reconstruction that classifies defects as superstructure defects, which may or may not involve the orbit, and infrastructure defects. The patients described in our series all had large, subtotal infrastructure defects, for which this algorithm recommends local flap reconstruction or a prosthetic obturator. The use of obturators works for many patients, but obtaining a proper fit and seal in an edentulous patient can be difficult, as there are no teeth on which to anchor the prosthesis. Five of the 16 patients in this series were edentulous. Furthermore, resection of such palatal tumors often requires removal of so much hard palate that too little remains to stabilize and support an obturator. Finally, because of exposure of proximal cranial nerves, 4 of the 16 patients in our series had exposed dura that needed protective covering. Although the algorithm recommends temporalis regional flaps for reconstruction of superstructure defects, we have found them particularly useful in reconstructing large infrastructure defects. These defects typically do not need to have osseous reconstruction if they occur in an edentulous patient, or are posterior enough not to incur stress during mastication. Thus, a free flap can be avoided in these instances. Total maxillectomy or orbital defects require more extensive reconstruction, and we have advocated the use of rectus abdominis myofascial free flap reconstruction in this instance.22
Cancer of the maxilla can be a lethal disease, and its treatment often leaves the patient with marked functional and cosmetic deficits. Use of the temporalis myofascial rotational flap has allowed expeditious treatment and rapid return of function, thereby maximizing the quality of life for the patient and minimizing the functional and cosmetic deficits. We have had favorable long-term results with the temporalis flap in this series. All but one of the patients were able to resume their preoperative diets. Critics have claimed that primary reconstruction hides local recurrences on postoperative surveillance examination. We have not had any local recurrences (although follow-up is limited on our most recent patients) and have used surveillance magnetic resonance imaging to monitor these patients because it can distinguish between recurrent tumor and temporalis flap tissue. Twelve of these patients have had implantation of a synthetic porous polyethylene prosthesis into the temporal fossa. We currently favor this technique should a patient desire recontouring of the temporal defect for cosmesis.
The complications encountered in this series have been related to temporalis flap bulk in the nasopharynx, causing posterior choanal stenosis and possibly eustachian tube obstruction. These have been easily treated with tympanostomy tube insertion in the ipsilateral ear and carbon dioxide laser debulking of the flap obstructing the posterior choana (patients 1 and 4). A split-thickness skin graft was used (patient 4) to prevent restenosis of the posterior choana after the laser procedure. Unfortunately, the patient died, and so long-term follow-up of this procedure was not possible. Reduction of temporalis flap bulk in the anterior nasopharynx may reduce or alleviate the symptoms related to excessive tissue in this area, but in general these problems have been minor and easily corrected.
Palatal malignancies frequently spread perineurally along the descending palate nerve and into the PPF. A combined intraoral and lateral temporal fossa approach allows for excellent visualization and dissection of the perineural spread of these tumors into the PPF and petrous apex for an en bloc resection of the tumor mass. Such large lesions that require subtotal palatectomies frequently do not provide sufficient support or seal for a prosthetic, nor does a prosthetic provide adequate dural protection after an adjacent craniectomy for resection of perineural spread into neural foramina. However, these defects can be easily reconstructed with a temporalis muscle rotational flap and provide velopharyngeal competence while allowing the patient to resume his or her preoperative diet, in conjunction with a denture plate if needed. This combined approach and this method of reconstruction should be considered an option for treating palatal malignancies, especially those with perineural spread.
Accepted for publication October 26, 2001.
This study was presented at the Fifth International Conference on Head and Neck Cancer, San Francisco, Calif, August 2, 2000.
We thank Annemarie B. Johnson for her help with the anatomic illustrations.
Corresponding author and reprints: J. Dale Browne, MD, Department of Otolaryngology–Head and Neck Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1034 (e-mail: email@example.com).