Superiorly based and island masseter muscle flaps for repairing oropharyngeal defects

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Summary

Introduction

Tumours of the posterior part of the mouth and/or the oropharynx are often diagnosed at advanced stages. Reconstruction in this region has advanced considerably during the last three decades. Although microsurgery has offered major progress and has obviously improved the patients’ outcome, the use of local and regional flaps generally remains an ideal solution for reconstruction.

Material and methods

Between January 1994 and December 2001, the defects resulting from resection in 22 out of 38 patients with retromolar and/or anterior faucial pillar squamous cell carcinomas treated at this institution, were repaired by one of two types of masseter muscle flaps. The first type is the superiorly based or cross-over masseter muscle flap, and the second type the island muscle flap (being a modification of the first type).

Results

The superiorly based masseter muscle flap was used in 12 patients and the island masseter muscle flap in 10. Both techniques offer a quick and reliable method for repairing oropharyngeal defects in oncologically “safe” cases. Neither require elaborate technique or aftercare.

Conclusion

The island masseter muscle flap has an advantage over the superiorly based masseteric flap, as it is more flexible, pliable for larger defects, and causes no postoperative trismus.

Introduction

Tumours of the posterior part of the mouth and/or oropharynx are usually squamous cell carcinomas, often diagnosed at advanced stages due to their oligosymptomatic early manifestations (Kimura et al., 2002; Antoniades et al., 2003). The optimal therapy for these tumours remains controversial, although a combined therapy is preferred (Grau et al., 2002). Oropharyngeal reconstruction presents a challenge since oncologically adequate resection of advanced tumours results in functional deficits in speech, swallowing, and mandibular mobility. (Barbosa, 1959; Langdon, 1989).

Reconstruction of the posterior part of the mouth and of the oropharynx has advanced considerably during the last three decades. The main goals of surgical reconstruction are structural and functional rehabilitation following oral-oropharyngeal tumour resection, together with low morbidity and mortality. Several flaps (local and regional, and free tissue transfer, with or without bone) have been used. The choice of reconstructive techniques is largely influenced by the surgeon's preference. Although microsurgery has demonstrated major progress and has obviously improved the patients' outcome, the use of local and regional flaps generally remains an ideal solution for reconstruction (Zoller et al., 1992; Werker, 2002).

Conley and Gullane (1978) introduced the masseter muscle flap as a reconstructive measure for the oropharynx. A few years later Tiwari and Snow (1989) and Langdon (1989) advocated the usefulness of this flap highlighting the minimal time and technical support required. The main disadvantage of both the superiorly based and the inferiorly based masseter flaps is the postoperative restriction of mouth opening (Langdon, 1989; Harrison, 2002), which is aggravated by intramuscular fibrosis, resulting from postoperative radiotherapy.

The purpose of this retrospective study is to report the use of two types of masseter muscle flaps in the repair of composite oropharyngeal defects. The first type concerns the superiorly based or cross-over masseter muscle flap, and the second one the island muscle flap, which is a modification of the first type.

Section snippets

Material and methods

Between January 1994 and December 2001, the defects resulting from resection in 22 out of 38 patients with retromolar and/or anterior faucial pillar squamous cell carcinoma treated at this institution, were repaired by one of the two masseter muscle flaps (Fig. 1). No patient had been previously treated and none had received preoperative radiation therapy. Neck surgery, excision of the primary tumour and marginal or segmental mandibulectomy were performed in all cases.

In all patients, a midline

Results

Signs of postoperative contraction of the flap and trismus were mostly associated with the superiorly based masseter muscle flap. One patient developed a small haematoma and two diabetic patients developed superficial infections controlled by irrigation and systemic antibiotics.

The superiorly based masseter muscle flap was used in 12 patients, while the island masseter muscle flap was used in 10. In all patients, the vitality of the flap was excellent and epithelisation was complete within 3

Discussion

Tissue repair following tumour ablation of the retromolar trigone and anterior faucial pillar is extremely demanding due to the multiple functions of the oropharyngeal region. Speech, swallowing, tongue mobility and Eustachian tube function may be seriously affected (Crecco et al., 1999; Genden et al., 2003).

Several methods of reconstruction have been used: primary closure, free skin grafts, tongue flaps, buccal fat pad, cheek flaps, myocutaneous flaps, free tissue transfer, masseter muscle

Conclusions

The masseter muscle flap offers a reliable method for repair of defects following cancer resection at the retromolar trigone and/or anterior faucial pillar regions. It is a safe, single stage procedure, which does not require elaborate technique or aftercare, and results in little cosmetic and functional loss postoperatively.

The island muscle flap should be preferred as it has an advantage over the superiorly based masseter muscle flap.

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