( 1995) 33, 149-l 51
Closure of palatal defect with full-thickness skin graft via Le Fort 1 maxillary access osteotomy B. T. Musgrove, S. G. Langton Muxillofacial
Unit, Manchester Royal Injirmary, Manchester
SUMMARY. A technique for resection of a palatal tumour via a Le Fort 1 maxillary access osteotomy is described. Access via the osteotomy allows intra-operative examination of the superior aspect of the palate and resection of the tumour without gross destruction of the nasal mucosa. The nasal mucosa provides a bed for a full-thickness skin graft to effect closure of the palatal defect.
Salivary gland tumours of the palate are typically resected via an intra-oral route, which usually results in oro-nasal or oro-antral fistula. The communication between the oral and nasal cavities is often a cause of significant morbidity, with both speech and mastication markedly compromised.1,2*3 Such defects can either be managed with a removable prosthesis or surgically. A prosthesis avoids the need for a surgical closure procedure and in the hands of a skilled prosthetist can produce satisfactory obturation. 4,5 However, discomfort, foul taste, odour and nasal regurgitation may occur, especially if fit is less than perfect. In an effort to avoid the use of an obturator, many surgical procedures have been developed to repair palatal defects including the tongue flap,3,7,8 temporalis muscle flap, I,9 buccal fat,l’ free radial forearm flap” and free jejunum with iliac crest.l’ This paper reports an approach to a minor salivary gland tumour of the palate via a Le Fort 1 maxillary access osteotomy, which affords visualisation of the tumour from above and allows closure by full thickness skin graft (Wolfe graft) to the nasal mucosa.
Fig. 1 - The nasal mucosa
a bed for grafting.
thickness skin graft (Wolfe graft) is harvested (Fig. 2) and sutured over the nasal mucosa (Fig. 3). A small pack placed over the graft and an acrylic plate protects the graft and prevents the development of a haematoma. The graft 1 week following surgery is shown in Figure 4. The plate is worn for a further 2 weeks. In the case illustrated examination at 3 weeks confirmed a satisfactory graft producing excellent oro-nasal seal with no leakage (Fig. 5). The patient remains well 18 months post-surgery.
Under general anaesthesia an area of palatal mucosa is defined around the lesion, including a 0.5 cm margin of clinically normal tissue. A standard Le Fort 1 maxillary osteotomy is performed, downfracturing the maxilla to reveal the superior aspect of the palate, which permits direct visualisation of the tumour from the nasal aspect prior to excision with an appropriate area of palatal bone. The maxilla is replaced in its preoperative position, fixed with miniplates (previously located on the intact maxilla) and the nasal mucosa is advanced to the palatal mucosa at the margins of the defect and sutured at the periphery (Fig. 1). A standard post-auricular full-
The Le Fort 1 maxillary osteotomy has an established place in surgical access to tumours of the nasopharyngeal region, and has been shown to be a versatile procedure when employed in this role.13 In the technique described in this paper the procedure allows examination of the superior aspect of the palatal bone and nasal mucosa, and permits excision of the tumour under direct vision from above. Full thickness skin grafting to the advanced nasal mucosa to repair the palatal defect is therefore possible and provides excellent closure and oro-nasal seal. The graft is 149
Fig. 5 - Graft
Fig. 2 -Harvesting
Fig. 3 - Wolfe
at 3 weeks.
surgeons. However, as Busic et al3 point out, there is no single reconstructive procedure that is satisfactory for all types of palatal defect or indeed for similar defects in different patients. The technique described relies on sufficient nasal mucosa being available over the area of resection to provide a bed for the graft and may not be suitable for large palatal defects. Clearly, the benefits of any procedure require to be balanced against the possible risks. Although the case depicted sustained minimal morbidity from the Le Fort 1 osteotomy, reported problems have included necrosis of the maxilla,14 severe haemorrhage,15 damage to the endotracheal tube,16 third and sixth nerve palsies17,18 and loss of tooth vita1ity.l’ However, most of the major complications remain rare and indeed, the series of access Le Fort 1 osteotomies of Wood and Stell13 had minimal complications. CONCLUSION A simple method of closure of an oro-nasal fistula is described, employing a Le Fort 1 osteotomy for access. Effective closure and excellent function have been evident at periods up to 18 months after surgery. References
Fig. 4 - Graft
at 1 week.
simple to harvest, the donor site is inconspicuous and the grafting procedure has in itself minimal morbidity when compared to flaps such as the temporalis muscle or the radial forearm. The technique of Le Fort 1 osteotomy is familiar to most oral and maxillofacial
1. Phillips JG, Peckitt NS. Reconstruction of the palate using bilateral temporalis muscle flaps: a case report. Br J Oral Maxillofac Surg 1988; 26: 322. 2. Hatoko M, Harashina T, Inoue T, Tanaka I, Imai K. Reconstruction of the palate with radial forearm flap; a report of 3 cases. Br J Plas Surg 1990; 43: 350. 3. Busic N, Bagatin M, Boric V. Tongue flaps in repair of large palatal defects. Int J Oral Maxillofac Surg 1989; 18: 291. 4. Watson RM, Gray BJ. Assessing effective obturation. J Prosthet Dent 1985; 54: 88. 5. Groetsema WR. Overview of the maxillofacial prosthesis as a speech rehabilitation aid. J Prosthet Dent 1987; 57: 204. 6. Gillespie CA, Kennan PD, Ferguson BJ. Hard palate reconstruction in maxillectomy. Laryngoscope 1986; 96: 443. 7. Klopp C, Schurter M. The surgical treatment of cancer of the soft palate and tonsil. Cancer 1956; 9: 1239. 8. Johnson PA, Banks P, Brown AE. Use of the posteriorly based lateral tongue flap in the repair of palatal fistulae. Int J Oral Maxillofac Surg 1992; 21: 6.
9. Bradley PF, Brockbank J. The temporalis flap in oral reconstruction. J Maxillofac Surg 1981; 9: 139. 10. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986; 44: 435. 11, Batchelor AG, Palmer JH. A novel method of closing a palatal fistula: the free fascial flap. Br J Plast Surg 1990; 43: 359: 12. Inoue T. Harashina T. Asanami S, Fuiino T. Reconstruction of the hard palate using free iliac do&covered with a jejunal flap. Br J Plast Surg 1988; 41: 143. 13. Wood GD, Stell PM. Osteotomy at the Le Fort level. A versatile procedure. Br J Oral Maxillofac Surg 1989; 27: 33. 14. Parnes EI, Becker ML. Necrosis of the anterior maxilla following osteotomy. Oral Med Oral Surg Oral Path01 1972; 48: 326. 15. Lanigan DT, West RA. Management of postoperative haemorrhage following Le Fort 1 maxillary osteotomy. J Oral Maxillofac Surg 1984; 42: 367. 16. Pate1 C, Cotten S, Turndorf H. Partial severance of a nasotracheal tube during a Le Fort 1 procedure. Anaesthesiology 1980; 53: 357. 17. Carr RJ, Gilbert P. Isolated partial third nerve palsy following Le Fort 1 maxillary osteotomy in a patient with cleft lip and palate. Br J Oral Maxillofac Surg 1986; 24: 206.
via Le Fort
18. Watts PG. Unilateral abducent nerve palsy; a rare complication following a Le Fort 1 maxillary osteotomy. Br J Oral Maxillofac Surg 1984; 22: 212. 19. Kahnberg K-E, Engstrom H. Recovery of maxillary sinus and tooth sensibility after Le Fort 1 osteotomy. Br J Oral Maxillofac Surg 1987; 25: 68.
The Authors B. T. Musgrove FRCS, FDSRCS Lecturer and Honorary Consultant S. G. Langton FRCS, FDSRCPS Lecturer and Honorary Senior Registrar Maxillofacial Unit Manchester Royal Infirmary Manchester M 13 9WL Correspondence
Paper received 31 January Accepted 22 June 1994
to B. T. Musgrove