Reconstruction of the Oropharynx

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CHAPTER 101 Reconstruction of the Oropharynx

The complexity of the human upper aerodigestive tract renders oropharyngeal reconstruction one of the most challenging tasks in the field of head and neck surgery. Successful reconstruction requires detailed knowledge of the normal anatomic and physiologic mechanisms of swallowing and velopharyngeal competence that exist in this area, in combination with the surgical expertise and insight to execute various techniques for a multitude of defects. This chapter discusses the various options for reconstruction of oropharyngeal defects and the decision-making process the surgeon must go through when encountering specific defects in this area.

Oropharyngeal reconstruction has gone through several stages in the past 25 years. Reconstruction of this area before the advent of the pectoralis major flap proved difficult and was commonly complicated by wound infection and breakdown. First described in 1979 by Ariyan1 and Baek,2 the pectoralis major myocutaneous flap revolutionized head and neck reconstruction at that time and added a new dimension to our reconstructive capability. This was soon followed by the introduction of free tissue transfer with the belief that reconstructions that rendered the patient functionally and esthetically superior could now be performed. These effective reconstructions are even more important as the prognosis for advanced oropharyngeal cancer has improved.3

Several factors influence reconstructive decision making. First, one must consider the overall medical condition of the patient, with particular emphasis on comorbidities such as peripheral vascular disease, diabetes, previous radiotherapy, and nutritional insufficiency, because these conditions may adversely affect postoperative wound healing. A detailed medical history should be obtained to determine the patient’s ability to tolerate extensive surgery. Severe coronary artery disease, chronic obstructive pulmonary disease, or poor overall functional status or prognosis may preclude a complicated time-consuming reconstruction. Instead, a reliable and more expedient reconstructive technique should be considered. The reconstructive surgeon should have a detailed preoperative discussion with the patient to determine which donor site would be most appropriate given the patient’s lifestyle and expectations.

Careful three-dimensional (3D) analysis of the defect is critical at the conclusion of the ablative portion of the case. The size of the primary tumor, specifically the T stage, has been shown to directly correlate with the functional status of the patient in the postoperative period.4,5 The soft tissue and the bony defect should be determined. The purpose of the soft-tissue reconstruction is to re-establish bulk, sensation, and a re-epithelialized passageway for respiration and deglutination. The dimensions of the defect should be measured with a ruler, or a template of the defect can be fabricated with Esmarch (Microtek Medical, The Netherlands). The subsites of the oropharynx involved should be determined. Although this chapter focuses on oropharyngeal reconstruction, these defects do not exist in isolation. Factors such as laryngeal and mandibular arch preservation must be taken into account before determining the reconstruction of choice. For example, a base of tongue defect in combination with a supraglottic laryngectomy may be best reconstructed with a sensate fasciocutaneous free flap, as opposed to a musculocutaneous flap that cannot be reinnervated. Also, surgeon and hospital factors come into play in the decision-making process. A surgeon will decide on a reconstructive technique on the basis of his or her experience and level of training. Hospital factors include the availability of an intensive care unit experienced in monitoring head and neck patients with free flaps, microsurgical instrumentation, and appropriate paramedical staff for rehabilitation.

Cost has also become a factor in recent times. Managed care has affected most American centers, and more cost-effective methods of reconstruction are often stressed elsewhere. The use of free tissue transfer for oropharyngeal reconstruction has been compared with pedicled soft tissue transfer. These studies have demonstrated that the operative costs are higher in the free flap group; however, the overall costs are lower compared with the pectoralis major flap.6,7 A more recent study, however, showed no evidence that cost or morbidity differed in the two groups.8 In other areas where universal health care systems are in place, operative time and long waiting lists may dictate which form of reconstruction is used. All things being equal, however, the most important determining factor should be the resultant quality of life for the patient. The method of reconstruction chosen must give the patient the best chance of re-establishing an oral diet, intelligible speech, and a stable airway without cannulation. It has been shown that quality of life and functional status can be restored at 6 months after microvascular reconstruction for advanced (T3, T4) oropharyngeal cancers, and most have improved post-treatment scores at 1 year.9

Options for Reconstruction

Various reconstructive options are available for defects of the oropharynx. It is helpful for the surgeon to consider the reconstructive ladder and to work through the possible techniques for a given defect (e.g., soft palate versus base of tongue, starting with the simplest and progressing to the more complicated) (Fig. 101-1). The simplest method of reconstruction that achieves the highest level of function should be chosen.

No reconstruction by tissue graft or transfer, i.e., healing by secondary intention, is the simplest form of reconstruction. This is not commonly used for open approaches, given the size and complexity of most oropharyngeal defects; however, both authors have used this as their method of first choice after transoral laser resections of the tonsil and base of tongue, as well as smaller soft palate defects. It is successful even for deep resections extending into the parapharyngeal space. Healing by secondary intention can be used for small defects typically less than 4 to 5 cm, although it is not advisable when the oropharyngeal wound communicates with the neck. The advantage of this method is in its simplicity and the tendency of the granulating bed to mimic the native tissue when fully healed. The main disadvantages are the contracture and tethering that can occur when unopposed surfaces heal. This can be particularly a problem when used for larger resections of the tonsil that are taken down to the parapharyngeal fat pad, and/or forward into the retromolar trigone, mainly because of anterior displacement of the soft palate, resulting in velopharyngeal incompetence. Healing by secondary intention can also be supplemented by the use of a prosthesis for obturating defects of the palate.

Primary closure is sometimes possible after surgical ablation of an oropharyngeal tumor. It should only be considered when a tension-free closure is obtained without distortion of the normal anatomy of the region. A prospective case-comparison study by McConnel and colleagues challenged the idea of free and pedicled flap reconstruction of the oral cavity and base of tongue. They concluded that speech and swallowing are superior with primary closure for defects of 60% or less of the tongue base.10 Although there are inherent flaws in the study and the defects addressed were small, their findings bring to light the need for objective research on reconstructive efforts of the oropharynx and its effect on speech and swallowing.

Skin grafts can be used effectively for small defects of the posterior pharyngeal wall that are not amenable to primary closure. A bolster dressing is used to decrease shearing forces on the graft, and a tracheotomy should usually be performed in conjunction with this. Skin grafting can also be used in combination with healing by secondary intention. The graft is used in critical areas such as the glossotonsillar sulcus to decrease contracture formation and to maintain tongue mobility.

Local Flaps

Local flaps have not gained popularity for oropharyngeal reconstruction. Tongue flaps are of historical interest and are mentioned here only to be discouraged. The flap is performed by dividing the anterior tongue and then rotating it posteriorly into the surgical defect. It is clear that the use of this flap leads to restriction in the mobility of the remaining tongue and leads to impaired oral and oropharyngeal function.11,12

By comparison, the palatal island flap does have a role in oropharyngeal reconstruction.13 The flap is composed of hard palatal mucoperiosteum and is based on a single greater palatine artery (Fig. 101-2). It is performed by sharply incising the mucoperiosteum of the hard palate approximately 1 cm medial to the maxillary alveolus. A periosteal elevator is then used to elevate the flap, and the base is narrowed accordingly. The hard palate is left to remucosalize. The flap provides thin but relatively nonpliable tissue for reconstruction.

The uvulopalatal flap can be used for limited lateral soft palatal defects.14 Most of the uvula and the contralateral soft palate must be intact for this flap to be used. The uvula is denuded of its mucosa and is then rotated into the defect (Fig. 101-3). A releasing incision is made in the contralateral anterior and posterior tonsillar pillars to increase the arc of rotation. Other local flaps such as inferior and superior pharyngeal flaps, the superior-constrictor advancement-rotation flap (SCARF), and the buccinator myomucosal flap, should also be considered as local flap options for palatal defects,15,16 but all must be measured against the gold standard procedure for through-and-through defects, which is the folded radial forearm flap.

Regional Flaps

Before the advent of free tissue transfer, oropharyngeal reconstruction was most commonly performed with regional flaps. Currently, these flaps remain an excellent option for selected defects of the oropharynx because they are reliable and relatively easy to harvest. The pectoralis major flap has served as the workhorse of head and neck reconstruction for more than 2 decades (Fig. 101-4). The flap is based on the thoracoacromial artery, which originates from the second part of the axillary artery. It passes medial to the pectoralis minor and courses on the undersurface of the pectoralis major muscle. The lateral thoracic artery may contribute to the blood supply of the flap as well.17 The flap can be used as a myocutaneous or a myofascial transfer.18 The bulk of the flap can make it difficult to fold into a complex oropharyngeal defect, and this flap is therefore not the technique of choice at most centers.

The platysma myocutaneous flap was initially proposed for oropharyngeal reconstruction in 1978.19 The flap has not gained wide acceptance in the literature, and many believe it is an underused technique for head and neck reconstruction (Fig. 101-5). Koch20 reported on 34 patients who had this flap performed for head and neck defects. Postoperative fistula formation was noted in five patients (15%), and flap desquamation was seen in six cases (18%). Donor site complications were rare, with two cases developing distal skin loss at the closure site. Complications were not related to previous radiation. The platysma myocutaneous flap is based on the submental branch of the facial artery. Ligation of the facial artery during neck dissection does not compromise the blood supply to the flap.12,21 The flap can be harvested in 20 to 30 minutes and can be done with or without a neck dissection. It provides a thin, pliable skin paddle that is ideal for oropharyngeal reconstruction. The main disadvantage cited in the literature is the reliability of the flap because flap-related complication rates have been reported to be as high as 40%.22

The temporal area provides two regional flaps for oropharyngeal reconstruction. The temporoparietal fascial flap provides thin, highly vascular tissue for reconstruction.23 Its blood supply is based on the superficial temporal artery and vein. It can be used either as a pedicled or free tissue transfer if this is required to enhance inset of the flap. An outer table calvarial bone graft superior to the temporal line may also be harvested with the flap.24 Identification of the vascular pedicle by Doppler ultrasonography is done at the initiation of the harvest. A preauricular incision is then made and is carried superiorly through the temporal scalp and can be extended to or above the vertex if necessary (Fig. 101-6). The dissection is begun superiorly just deep to the hair follicles. Care must be taken when dissecting the anterior branch of the artery because this is accompanied by the frontal branch of the facial nerve. The fascia is then divided by carrying the dissection to the level of the superficial layer of the deep temporal fascia. It is then narrowed inferiorly; at this point the anterior branch of the artery is divided close to the origin of the posterior branch of the superficial temporal artery, being aware of the facial nerve. The flap is then tunneled into the oropharynx and is sutured into the defect. A skin graft may be used on the flap but is not necessary because the surface of the flap will remucosalize. Similarly, the temporalis muscle can be tunneled into the oropharynx after removal of the zygomatic arch, which is later replaced. It is less commonly used than the temporoparietal flap because of its added bulk, limited arc of rotation, and difficult tunneling into the defect, although in experienced hands and with a fascial extension it has proved useful in soft palate and pharyngeal wall defects.25

The latissimus dorsi musculocutaneous flap is another viable option for reconstructing oropharyngeal defects.26,27 It can be used either as a pedicled or free flap, especially for total glossectomy defects (Fig. 101-7). The flap is based on the thoracodorsal artery, which is a branch of the subscapular system of vessels. The subscapular artery arises from the third part of the axillary artery. The latissimus muscle arises from the thoracolumbar fascia, the lower six thoracic vertebrae, and the iliac crest and inserts onto the medial surface of the humerus. Several musculocutaneous perforators supply the overlying skin and are more abundant in the upper two thirds of the muscle. The flap is harvested by first incising the lateral aspect of the skin paddle and then extending this superiorly following the lateral border of the muscle into an axillary crease. The pedicle is found along the lateral border of the muscle 8 to 10 cm from the midpoint of the axilla. The medial skin paddle incision is next fashioned, and tacking sutures are placed between the skin and underlying muscle. The muscle is then divided distally and medially, and the pedicle is traced into the axilla after identifying and dividing the branch to the serratus anterior. Finally, the superior muscle cut is made protecting the vascular pedicle. If the flap is to be used as a pedicled transfer, a tunnel is made above or below the pectoralis major muscle. We have had success with a tunnel above the muscle in combination with a partial-thickness myotomy of the lateral aspect of the pectoralis major.

Less commonly, the trapezius musculocutaneous flap may be used. It is generally not a good option because trapezius muscle sacrifice leads to significant shoulder dysfunction and chronic pain. Other factors that make it an unpopular choice are the flap’s limited arc of rotation and need for patient repositioning in the lateral decubitus position. By comparison, the longus colli muscle flap can be used to reconstruct defects of the lateral and posterior pharyngeal wall.28 There have been reports on 13 patients who had pharyngeal reconstruction with this regional technique with no postoperative fistulas. The flap is reported to have minimal, if any, donor site complications; however, three patients had postoperative Horner’s syndrome, and there is a question as to whether this was related to the ablation of high pharyngeal wall tumors as opposed to a flap-related problem. Experience with the longus colli flap is limited, and more evidence is necessary before the flap can be championed for oropharyngeal reconstruction.

Free Tissue Transfer

The introduction of free tissue transfer has been the greatest advance in the area of oropharyngeal reconstruction. This technique is available at most tertiary care centers. As stated previously, reconstructive advances have not changed the prognosis for oropharyngeal cancer.3 Quality of life and postoperative function are then paramount when deciding on reconstructive efforts. Free flap reconstruction has been found to be superior from a functional standpoint in both prospective and retrospective studies.7,9 In the following sections, commonly used free flaps from their respective donor tissues are outlined, and details of their use are addressed.

Fasciocutaneous

The radial forearm flap is the most commonly used free flap for oropharyngeal reconstruction (Fig. 101-8). The flap was initially described in the Chinese literature. The flap is based on the radial artery and the accompanying paired venae comitantes. The cephalic vein is also routinely incorporated into the flap and serves as the superficial venous drainage system. The lateral antebrachial cutaneous nerve provides sensation to the forearm skin, and the flap can be successfully neurotized to improve pharyngeal sensation.29 Sensory recovery is also present in most patients even when a neural anastomosis is not performed, and more commonly occurs in fasciocutaneous flaps than musculocutaneous flaps.30 This reinnervation is, however, often incomplete and unpredictable, and it is not valid to rely on spontaneous sensory recovery of free flaps in oral and oropharyngeal reconstruction.31 The skin paddle of the forearm flap is thin and pliable and thus makes it ideal for a variety of oropharyngeal defects. In fact, because of its thinness it can be used for reconstruction of large defects after transoral resections, inset through the mouth albeit with greater technical difficulty. It can be elevated either deep or superficial to the investing fascia of the forearm, depending on the bulk required. A preoperative Allen test should be performed on all patients. The flap is elevated under tourniquet control. The skin paddle is incised along its ulnar, distal, and radial aspect. The flap is then elevated at the desired level, preserving the sensory branches of the radial nerve. The level of dissection is taken to the subfascial level as the pedicle is approached. The pedicle is then identified between the medial head of the brachioradialis and the flexor carpi radialis and is then divided. A lazy S-shaped incision is fashioned into the antecubital fossa, and the cephalic vein is incorporated into the flap, leaving a generous cuff of fat and fascia to prevent kinking. An external skin monitor can be incorporated into the flap proximally if the main skin paddle is not visible for evaluation.32 The radial artery is dissected to its origin and is divided distal to the radial recurrent artery. We routinely incorporate the deep and superficial venous systems and generally have two veins for performing venous anastomoses. The donor site is covered with a split-thickness skin graft, and a bolster and cast is left in place for 1 week.

The lateral thigh free flap is another commonly used fasciocutaneous flap for oropharyngeal reconstruction. It was first described by Baek33 in 1983 and has since been used extensively in the head and neck with excellent results. Hayden34 reported a 98% success rate in 43 pharyngeal reconstructions, of which 11 were used in the oropharynx. The flap is usually based on the third perforator of the profunda femoris artery, which terminates in the intermuscular septum between the long head of the biceps femoris and the vastus lateralis. Occasionally, the second or fourth perforator will serve as the dominant blood supply to the flap. The lateral femoral cutaneous nerve provides sensation to the skin of the lateral thigh and may be incorporated into the flap. The flap is typically harvested as an ellipse of skin whose epicenter is based on the midpoint of the intermuscular septum between the greater trochanter and the lateral epicondyle of the femur. The dominant perforator is identified in the subcutaneous plane and is then traced through the biceps femoris to the main pedicle. Release of the adductor magnus from the linea aspera assists dissection of the main pedicle, which is divided distal to the origin of the dominant perforator and is then dissected proximally, where its diameter is usually 2 to 5 mm. Paired venae comitantes serve as the venous drainage of the flap. These veins typically converge before entering the deep femoral vein, and this vein ranges in size from 3 to 5 mm. The advantages of this flap are the ability to close the donor site primarily and the relative separation between the ablative site and the donor site, which tends to assist a simultaneous harvest. The disadvantages of the flap are the prevalence of atherosclerosis in the donor artery and the variability of the donor perforators to the skin paddle.

The anterolateral thigh flap has gained recent popularity in head and neck reconstruction and is now more commonly used than the lateral thigh flap. It was first described by Song and colleagues in 1984 and has been used extensively in Asia ever since.35 The flap is most often supplied by perforating vessels arising from the descending branch of the lateral circumflex femoral artery. This artery courses in the intramuscular space between the vastus lateralis and rectus femoris muscles and provides musculocutaneous and septocutaneous perforators to the overlying skin of the anterolateral thigh. The flap can be harvested as a subcutaneous, fasciocutaneous, myocutaneous (a portion of the vastus lateralis muscle may be incorporated for ease of harvest or to increase bulk), or adipofascial flap, giving this flap the required versatility for reconstructing a variety of head and neck defects.36 The advantages of this flap are its versatility, as mentioned previously, a potentially long vascular pedicle (16 cm) of excellent caliber (2 to 3 mm), low donor site morbidity, and the ability to harvest the flap simultaneously with an ablative team. The main disadvantage relates to the variations in the vascular pedicle, which may exist at the time of harvest.36 Also, with the incidence of obesity in Western countries the flap donor is bulkier; thus the flap has not gained widespread use in North America37 and is usually too thick for base of tongue or palatal reconstruction. Wei and colleagues reported on their experience with 475 anterolateral thigh free flaps used for defects of the head and neck.38 The overall flap survival rate was approximately 95%. The authors concluded that the thigh flap has potential in many Asian patients because it is as thin as the forearm flap and has essentially replaced the forearm flap at their center.

The lateral arm flap was described by Song in 1982 and was specifically applied to head and neck reconstruction by Sullivan 1 decade later.39,40 Civantos41 reported on the use of this flap in 28 head and neck defects, of which 14 encompassed the oropharynx. The flap success rate in this series was 100%. The authors concluded that this flap is ideal for oropharyngeal reconstruction because it incorporates thin skin from the proximal forearm, which is ideal for reconstructing the pharyngeal wall, and thick skin from the upper arm, which can be used in the tongue base where additional bulk is sometimes required. The flap is supplied by the posterior radial collateral artery, which is a terminal branch of the profunda brachi artery. It courses in the lateral intermuscular septum between the triceps posteriorly and the brachialis and brachioradialis anteriorly. Sensation to the flap is provided by the posterior cutaneous nerve of the arm. The flap is harvested from the nondominant arm without the use of a tourniquet. The desired skin paddle is based on the lateral intermuscular septum that topographically is located between the lateral epicondyle and the V-shaped insertion of the deltoid on the humerus. The flap can also be extended distally over the upper forearm to achieve additional pedicle length. The pedicle is identified between the previously described muscles and is divided distally. The radial nerve is identified along the anterior aspect of the pedicle and is preserved, dissecting free the posterior cutaneous nerve of the arm. The deltoid is released, and the radial nerve and pedicle are followed into the spiral groove. The pedicle is then divided at this point. Wide undermining of the skin is performed, allowing for primary closure of the donor site in most cases. The main advantage of this flap is that the feeding vessels are terminal and nonessential for perfusion of the arm. Also, the donor site may be closed primarily and may be more aesthetically pleasing than the forearm flap. The disadvantages of the lateral arm flap are the risk to the radial nerve and the relatively small caliber of the donor vessels.

Musculocutaneous Flaps

The latissimus dorsi myocutaneous free flap is our flap of choice in this category. The anatomy of the flap and the technique of harvest have been described previously in the regional flap section. The authors have found this flap most useful after total glossectomy. One of the authors (BHH) has described a useful technique of using an innervated latissimus myocutaneous free flap for reconstructing total glossectomy defects.42 The skin paddle is designed at a right angle to the course of the underlying muscle (see Fig. 101-7). The muscle is inset as a transverse sling on the undersurface of the mandible by suturing it to the remnant of the pterygoid, masseter, or superior constrictor, depending on what is available. The thoracodorsal nerve is then anastomosed to a suitable hypoglossal nerve, usually ipsilateral to the microvascular anastomoses. This gives the reconstructed tongue the ability to elevate superiorly toward the palate, thus enhancing the swallowing mechanism.

The rectus abdominis free flap is another viable option for selected defects of the oropharynx. It, too, has been used extensively for total glossectomy defects,4345 although it lacks the potential for convenient motor reinnervation. The flap is based on the deep inferior epigastric artery and vein, which provide several myocutaneous perforators that traverse the rectus muscle and terminate in the periumbilical skin. The skin paddle is designed with its epicenter above and lateral to the umbilicus because myocutaneous perforators are more abundant in this area. The superior portion of the skin paddle is incised, and the dissection is taken through the anterior rectus sheath to the underlying muscle. The fascia is then split vertically above the skin paddle to the costal margin. The lateral and inferior portions of the skin paddle are next incised, and the dissection is once again taken to the fascial level. A small cuff of anterior rectus fascia is preserved medially and laterally, taking care not to disrupt the cutaneous perforators. The fascia is then split vertically down to the pubic region. The rectus muscle is divided superiorly, taking care to ligate the superior pedicle. The muscle is then dissected free from the posterior rectus sheath, and the dissection is then taken below the arcuate line, noting that the posterior rectus sheath is absent below this level. The vascular pedicle is identified below the arcuate line along the lateral deep aspect of the muscle. The inferior portion of the muscle is divided after a tunnel is made between the pedicle and the overlying muscle. The pedicle is then dissected inferiorly to its origin off the external iliac system. The anterior rectus sheath is reconstructed with a patch of Gore-Tex or Mersilene mesh, whereas the cutaneous defect is closed primarily after wide undermining of the abdominal skin. The flap is highly reliable in the head and neck. A review of 73 flaps used in the head and neck revealed only one flap failure.46 The vascular pedicle is long and of excellent caliber. The flap can be easily harvested and can be performed simultaneously with the ablative team. The main disadvantage of this flap is the donor site morbidity, progressive flap muscle atrophy, and the chance of abdominal wall herniation.

Osteocutaneous

Free osteocutaneous flaps are not generally used in isolated defects of the oropharynx. However, as stated previously, these defects often accompany other sites in the head and neck. These flaps are commonly used for extensive mandibular defects that extend to the central segment of the mandible or that portion anterior to the mental foramen. Our flap of choice for anterior mandibular defects has been the fibular osteocutaneous flap. Other widely used flaps for this purpose are the iliac crest and scapular flap. These defects are not addressed in this chapter. Lateral mandibular defects, however, are commonly found in combination with oropharyngeal defects, particularly in the case of retromolar trigone primary tumors. These mandibular defects are effectively reconstructed with a soft tissue flap with or without a mandibular reconstruction plate. A recent study at the M. D. Anderson Cancer Center specifically addressed posterior mandibular defects reconstructed with vascularized bone compared with those reconstructed with a free soft-tissue flap.47 They report that vascularized bony reconstruction of posterior mandibular defects results in superior speech, diet, and midline symmetry. The rectus abdominis free flap was used in 75% of the soft tissue reconstructions, which may have provided too much bulk for adequate function. Also, the group failed to perform detailed analysis of the oropharyngeal portion of the defect and the radiation protocols used on the cohort of patients. The authors’ preference has been to reconstruct all defects of the pharynx with a single flap.48 Several others, however, recommend using a free bone flap for mandibular reconstruction in combination with a soft tissue flap for reconstructing the remainder of the defect.

Site-Specific Defects

Soft Palate

The soft palate is critical for velopharyngeal competence because it serves as a dynamic muscular structure to effectively separate the oral and nasal passageways. Ablative surgery to the area may result in hypernasal speech, with obvious air escape or nasal regurgitation of food with swallowing. These problems can be greatly improved with functional palatal reconstruction. The goals of palatal reconstruction are to recreate a functional myomucosal velum and to establish closure of the oronasal communication.49 Several options are available for palatal reconstruction including the use of local, regional, and free flaps. Also, more conservative methods such as the use of a palatal prosthesis may be considered. Primary closure and healing by secondary intention are rarely indicated but may be considered when a marginal resection of the soft palate is performed and the muscular raphe of the palate is not violated. Skin grafting of soft palatal defects is of little use because it does not adequately reestablish the bulk necessary for through-and-through palatal defects, therefore leading to contracture and palatal dysfunction. We suggest referring to the reconstructive ladder for all defects of the oropharynx.

Prosthetic obturation is the traditional means of reconstructing palatal defects. It is available at most academic centers and is usually performed by a maxillofacial prosthodontist. It remains the method of choice for defects of the hard palate.50 A prosthesis can also be used effectively to obturate a combined defect of the hard and soft palate or a total soft palate defect. Isolated defects of the soft palate, however, are among the most difficult to treat with a prosthesis.51 Prosthetic rehabilitation of soft palatal defects is often functionally inferior because the prosthesis lacks the dynamic capability of the native palate.52 Also, the prosthesis may irritate the remnant palate and result in patient discomfort and the need for multiple adjustments. Yoshida and colleagues53 compared surgical and prosthetic reconstruction for speech disorders after ablative surgery of the soft palate. All surgical reconstructions were performed with a free radial forearm flap. They concluded that defects extending into the posterior edge of the soft palate are best reconstructed surgically because they believe patients achieve better restoration of speech and function. In cases in which a posterior band of soft palate remained, half of the patients reconstructed with an obturator had excellent restoration as tested by a standard speech intelligibility score.

If the decision is made to obturate a defect, preoperative impressions of the palate are made and the initial obturator is fabricated on the basis of the planned area of resection. The obturator is positioned in the operating room with the patient under general anesthesia after frozen section analysis of the margins has been completed, and negative margins are confirmed. The obturator can be fixated to existing teeth if available. Edentulous patients can have an upper denture made with a palatal extension to fill the defect. Patients can resume an oral diet immediately after surgery, and hospital stay is generally short. Often a subsequent interim prosthesis and finally a permanent prosthesis must be made to maximize function as the wound contracts.

Local flaps are an excellent option for reconstructing soft palatal defects in cases in which less than 50% of the palate has been resected. The uvulopalatal flap has been used successfully for marginal defects of the posterior soft palate. The uvula and contralateral soft palate must be intact for this flap to be used (see Fig. 101-3). Zohar and colleagues49 first reported on the use of this flap in five patients to close small to moderate defects of the lateral soft palate. None of the patients had evidence of velopharyngeal insufficiency postoperatively. Zohar and colleagues concluded that the uvulopalatal flap is a technically simple technique without significant donor site morbidity and satisfies the two goals of soft palatal reconstruction. More recently, Gillespie and Eisele14 reported on 18 patients in whom the uvulopalatal flap was used for soft palatal reconstruction. A total of 11 patients had the flap used alone, whereas the flap was used in combination with a free radial forearm flap, pectoralis major flap, and a skin graft in four, two, and one patients, respectively. All flaps survived. One flap partially dehisced but healed uneventfully. Of the 11 patients who had reconstructions with the flap alone, nine had normal speech, whereas two had mild hypernasal speech. All patients with T1 tumors had normal speech (six of six). The remaining five patients had T2 lesions. By comparison, all six patients with T1 tumors had no evidence of dysphagia, whereas 40% (two of five) of the patients with T2 tumors had dysphagia requiring G-tube alimentation. The authors concluded that postoperative speech and swallowing function depends on initial tumor stage and the extent of the resection and that the uvulopalatal flap is an effective method of soft palate reconstruction either alone or in combination with other methods of reconstruction for selected oropharyngeal defects. We have used the uvulopalatal flap successfully in our practices. One of the authors (SMT) has used this flap in combination with the platysmal myocutaneous flap for tumors of the retromolar trigone. The uvulopalatal flap is used for the soft palatal defect, and the platysmal flap is used for the lateral pharyngeal and retromolar trigone reconstruction.

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