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Reconstruction of palate defects requires a detailed knowl-edge of the local anatomy, and an understanding of the var-ioularprea nLuon

Suture tissue gently and with large bites of tissue tominimize tension and interference with blood supply at

TheAdd

109dois options available to the surgeon. This may be particu-ly important in cases of large defects, or when radiation orvious surgeries have compromised local tissue.1 There areumber of general principles described by Harvey3 andskin4 that should be followed when considering surgery a patient with a palate defect:

Make flaps large compared with the size of the defect tominimize tension.

Preserve the vascular supply to flaps by elevating ade-quate underlying connective tissue. For hard palate ep-ithelium, this means elevating the mucoperiosteum asone layer and avoiding the palatine artery, which pene-trates the palatine bone approximately 1 cm medial tothe carnassial tooth and then runs caudally and rostrallyparallel to the midline.

the wound edges.

Suture materials used are usually 3/0, 4/0, or 5/0 absorbablesuture material, depending on the size of the animal, type ofrepair being performed, and type of tissue being sutured (hardpalate mucosa, soft palate mucosa, or buccal mucosa). This au-thor generally prefers the use of polydioxanone, although otherabsorbable and nonabsorbable suture materials have also beenutilized. If knots are left on the epithelial surface, they will usu-ally slough in 3 to 4 weeks regardless of the type of suturematerial used.3

There are several reports of management of palate defectsin dogs and cats, with a variety of techniques described.Techniques that have been used for reconstruction or man-agement of palate defects include local flaps,3,5-8 axial patternflaps,1,9 distant tissue with use of a rostral tongue flap,10 freetissue transfer with microvascular anastomosis,2 and pros-thetic appliances.11-14 The aim of this article is to describe the

Animal Medical Center, New York, New York.ress reprint requests to Ramesh K. Sivacolundhu, BVMS, MVS, FACVSc,se of Local and Axial Pateconstruction of the Hardmesh K. Sivacolundhu, BVMS, MVS, FACVS

There are numerous conditions that may reReconstruction of these defects may be diffitissue availability. The majority of palate delocal and/or axial pattern flaps, while other mtransfer and prosthetic implants are requiredescribes the use of local and axial pattern flpalate.Clin Tech Small Anim Pract 22:61-69 200

KEYWORDS palate, flap, defect, mucoperiosteadog, cat

efects in the hard and soft palate may result from con-genital abnormalities, resection of neoplasms, trau-

tic injuries, severe peridontal disease, tooth removals,ere chronic infections, and, secondarily, to surgical andiation therapy.1-5 Reconstruction of these defects canchallenging. The area concerned presents a number ofatomical limitations, with difficulties in exposure andess to affected areas, and limited tissue available foronstruction of defects. In addition, the repair mustthstand mechanical stresses induced during masticationd deglutition.1useha

The AnimalMedical Center, 510 East 62nd Street, New York, NY 10021-8314. E-mail: ram.siva@amcny.org

6-2867/07/$-see front matter 2007 Elsevier Inc. All rights reserved.:10.1053/j.ctsap.2007.03.005n Flaps ford Soft Palate

n defects of the hard and soft palate.e to anatomical limitations and limitedeven when large, may be closed usingdvanced techniques such as free tissuesmaller number of cases. This articlethe reconstruction of the hard and soft

vier Inc. All rights reserved.

sposition, axial pattern, angularis oris,

Suture tissues to freshly incised epithelium. A flap su-tured to an intact epithelial surface will not heal. Inci-sions should be made with a scalpel blade rather thanscissors to minimize crushing injuries.

Avoid the use of electrosurgery or cauterization to con-trol bleeding.

Where possible, arrange suture lines so they are situatedover connective tissue rather than over the defect,thereby preventing drying and contamination of theconnective tissue side of the flap and decreasing the riskof dehiscence.of local and axial pattern flaps in the reconstruction of therd and soft palate.

61

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62 R.K. Sivacolundhucal Flaps for the Hard Palatemerous local flaps have been used to reconstruct defectsthe hard palate. These include mucoperiosteal flaps, mu-eriosteal releasing incisions, local flaps from the soft pal-, buccal mucosal flaps, and double reposition flaps.7,8,15-18

ucoperiosteal Flapsd Releasing Incisionscoperiosteal flaps are relatively simple to perform, beingndful of the location of the palatine artery medial to thenassial tooth. While a single overlapping mucoperiostealp may be used,7 this may interfere with bone union in thee of cleft palate.19 Achieving a two-layer closure is prefer-le to allow a more anatomic closure and potentially alloweous bridging of the bone defect.19

Bipedicle flaps are most often used for closing cleft palatefects involving the hard palate (Fig. 1). They are easily

Figure 1 (A) Incisions are created medially and laterally inflaps are elevated, taking care to avoid the palatine artery. (

and the bipedicled flaps are sutured to reconstruct the oral mucosarapidly. (Color version of figure is available online.)ated by performing releasing incisions in the hard palatecosa longitudinally along the length of the defect, adjacentd medial to the dental arcade.8 The flap has attachmentsintained rostrally and caudally. Incisions are also madeproximately 2 mm away from the edge of the midline de-t. Elevation of the flap continues from medial to lateral,ing careful to avoid the palatine artery. A simple hinged-p is created by elevating the mucosa adjacent to the defect,tinuous with the nasal mucosal, and hinging it across the

fect. The flap is sutured primarily using simple interruptedures, thereby reconstructing the nasal mucosal defect. Theedicled flaps may then be mobilized to reconstruct thel mucosa, again using simple interrupted sutures.19 It isnecessary to repair the resulting lateral defects with exposedatine bone since these defects will epithelialize rapidly.8,19 Ane free-graft from the medial tibia has been placed betweenreconstructed oral and nasal mucosa to encourage bone

mation,18 although this step appears to be unnecessary.19

ucoperiosteum of the hard palate. (B) The bipedicles are hinged and sutured to create the nasal mucosa,cremuanmaapfecbeflacondesutbiporaunpalbothefor. The donor site defects are left open and epithelialize

ThThofdepre

In of

Reconstruction of the hard and soft palate 63A rotational flap may be elevated from the hard palate.20

e hard palate mucosal flap has its base directed caudally.e edges of the defect are debrided to expose the cut edgethe epithelial surface. The flap is simply rotated in to thefect and sutured primarily (Fig. 2). If the palatine artery isserved, a long thin flapmay be harvested and even rotated

Figure 2 (A) A hard palate mucosal flap is created with itspalatine artery. (B) Following elevation, the flap is rotateavailable online.)

Figure 3 (A) Diagram of the hard palate showing the full-tpalate (A). The arrow indicates the proposed rotation of the(A) and the partial thickness defect in the soft palate remainpalate. Arrow indicates the proposed rotation of the flap. (C

and sutured (A). The mucosal defect in the hard palate was leftpartially closed (C). Reprinted with permission.50 to assist in closing large defects16 (Fig. 3), making thisp similar to an axial pattern flap.

cal Flaps from the Soft Palatea case reported by Beck and Strizek,16 a large caudal defectthe hard palate was covered using a hinged soft palate

irected caudally. Incisions are placed to preserve thethe defect and sutured. (Color version of figure is

ss defect (B) and the proposed hinge flap of the soft) The soft palate flap has been hinged in to the defect

. (C) The proposedmucoperiosteal flap from the hardmucoperiosteal flap has been rotated in to the defecthickneflap. (Bs open) The18fla

Lo

base dd in toopen (B), and the donor site in the soft palate was

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64 R.K. Sivacolundhucosal flap. Similar to hinging of mucoperiosteum adjacentsmaller defects to reconstruct the nasal mucosa, a hingedp was created with its base at the caudal edge of the hardlate. The flap was created and elevated, incorporating ap-ximately three-quarters of the thickness of the soft palate.e flap was folded forward so that the mucosal surface linedfloor of the nasal cavity, and sutures placed through bonenels were drilled in the hard palate. The majority of thenor site was closed primarily. With subsequent recon-uction of the oral mucosa using a mucoperiosteal rotationp, a two-layer closure was achieved16 (Fig. 3).A simple advancement flap of the caudal hard palate andrt of the soft palate has been described to close caudaldline hard palate defects.3 Advancement flap incisions areended caudally, and a flap is elevated comprising a partialckness of the soft palate. The dissection extends farough to be able to mobilize sufficient tissue cranially tose the defect without tension3 (Fig. 4).

ccal Mucosal Flapsccal mucosal flaps are very versatile flaps, are routinelyd in conjunction with maxillectomies, and are often per-med for reconstruction of defects following resection ofl tumors (Fig. 5). They are also useful for closing oronasalulae associated with tooth removal. Simple advancementps are most common. The dissection is begun at the lateralge of the defect and extended toward the lip margin. Labial

Figure 4 (A) Flap incisions are extended caudally from ththickness advancement flap. (B) The flap is advanced and sucosa and submucosa are separated from the remainder oflip, and the flap is undermined sufficiently to allow a

Figuclosion-free closure of the defect.21 Undermining should oc-r deep within the connective tissue to preserve vascularitythe flap.3 The flap is sutured to the mucoperiosteum of therd palate in one or two layers of simple interrupted sutures.Buccal mucosal transposition flaps based at the palatoglos- arches, as described by Sager and Nefen5 for correction oft palate defects (see Buccal mucosal flaps for the soft pal-), have also been used by the author to reconstruct caudal

ided defect in to the soft palate, creating a partial-primarily. (Color version of figure is available online.)tencuto ha

salsofatere 5 A large buccal mucosal advancement flap has been used tose a defect resulting from a left-sided maxillectomy.

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Reconstruction of the hard and soft palate 65rd palate defects. Random-pattern buccal mucosal trans-sition flaps have been used previously to close large rostralrd palate defects.15

uble Reposition Flapmbinations of the previously mentioned hard palateged flaps and buccal mucosal flaps may be used to achieveuble-layer closure of defects.17 The mucoperiosteum is in-ed for the planned flap to be 2 mm larger than the defect.e mucoperiosteum is elevated from the palate to the mar-of the fistula while preserving the basilar attachment offlap which serves as a hinge. After suturing the hinged

p in to the defect, a simple buccal mucosal advancementp is created and used to cover the hinged flap and denudedlatine bone. It is sutured to gingival and palate mucosang simple interrupted sutures17 (Fig. 6).While a single-layer closure may be more prone to dehis-ce than double-layer closures, it is often adequate forsure of defects if used in the absence of tension. Mostfects are successfully repaired if flaps can be apposed with-t tension and with a good blood supply.20

cal Flaps for the Soft Palatecal flaps that have been used in the soft palate include softlate mucosal flaps and releasing incisions, buccal mucosalps, and pharyngeal wall flaps.5,6,22,23 If possible, three-layersures of the soft palate are preferred with sutures in thesal mucosal, palatine muscles, and oral mucosa.19

ft Palate Mucosalaps and Releasing Incisionsis technique is often used to reconstruct cleft palate defectsolving the soft palate. Incisions are created in the nasale and oral side of opposite sides of the defect. Mucosalps are elevated from the nasal mucosa on one side, and oralcosa on the other. This will create two flaps, one based onoral side and the other on the nasal side of the defect. The

dth of each mucosal flap is 3 to 6 mm. The soft palate mayn be approximated and sutured in three layers. Simpleerrupted sutures are used with the knots placed on thesal side of the mucosa, simple interrupted sutures in thelatine muscles, and the same pattern and sutures placed onoral side. The result is a three-layer closure with offseture lines19 (Fig. 7). Double-layer closures have also beend.6

Similar to releasing incisions in the hard palate mucoperi-eum, releasing incisions may also be performed in the softlate. The incisions are extended through the mucosa of thepharyngeal mucosa of the soft palate, and through thesor veli palatini muscle. The incisions are extended cau-lly to the caudal edge of the nasopharynx19 (Fig. 7).

ccal Mucosal Flaps for the Soft Palateccal mucosal transposition flaps may be elevated bilater-y, based at the palatoglossal arches5 (Fig. 8). This tech-ue may be used for large defects in the soft palate. Anision is made in the mucosa with the base at the palato-

ssal arch, at the level of the caudal end of the hard palate.e length of the incision (and length of the flap) is deter-

foris tned by the width of the soft palate defect. The incision istinued in a dorsoventral direction with the width of the

p being determined by the craniocaudal length of the de-t in the soft palate. An incision parallel to the first one isn made back to the base of the flap. The length and widththe flap are designed to be greater than the length anddth of the defect to allow for shortening of the flap as it isated to avoid tension on the suture line. The flap is under-ned and elevated bluntly, taking care to avoid the deepial vein.5 If this flap includes the angularis oris artery andn, it may be considered an axial pattern flap1 (see Angu-is oris axial pattern buccal flap). The free edge of the softlate defect is incised to create nasal and oral edges foruring. One flap is rotated so that the mucosal side formsfloor of the nasopharynx, and the other is rotated sucht it forms the roof of the oropharynx. The flaps are suturedthe soft palate and nasopharyngeal mucosa using simpleerrupted sutures. If the flaps are reconstructing the caudalge of the soft palate, the caudal edges of both flaps areured to each other. The donor sites are closed using aple interrupted suture pattern.5

aryngeal Wall Flapsaryngeal wall flaps may also be used to reconstruct largefects in the soft palate. Hammer and Sacks22 reported onuse of a pharyngeal wall flap with the base dorsal to thesillar crypt. This technique was used to reconstruct a uni-eral congenital cleft of the soft palate.The technique was subsequently modified to include bi-eral pharyngeal wall flaps and a caudally hinged hard pal-mucoperiosteal flap for reconstruction of a bilateral hyp-lastic soft palate in a cat.23 A flap of mucoperiosteum wasated in the caudal hard palate, approximately 2 cm ingth and extending from the left to right dental arcades.re was taken to preserve the palatine arteries. The flap wasged 180 caudally to form the dorsal surface of the recon-ucted soft palate. Bilateral flaps were created in the pha-geal mucosa in the right and left pharyngeal walls. These of each flap extended from the caudal border of the lastlar to the cranial border of the tonsillar crypt. The dimen-ns of each flap were sufficient to be able to suture themoss the nasopharynx in an H-plasty configuration overmucoperiosteal flap, thereby approximating dimensionsa normal soft palate.23 The flap base may be extendedther caudally than the cranial border of the tonsillarpt.22 The incision is extended to deep within the submu-a to preserve the vascular supply.22 The lateral edges of thecoperiosteal flap were sutured to the edges of the pharyn-l wall, in the defects left by the creation of the pharyngealps. The pharyngeal flaps were then sutured over the mu-eriosteal flap and to the caudal border of the flap. Donors in the hard palate and pharyngeal walls were leften.22,23

xial Pattern and Distant Flapsw axial pattern flaps have been described in the literature

reconstruction of the palate.1,9 The most versatile of thesehe angularis oris axial pattern buccal flap.1

66 R.K. SivacolundhuFigure 6 (A) A mucoperiosteal flap is created (dotted line) to hinge it in to the defect. (B) The hinged flap is sutured into the defect and a buccal mucosal advancement flap is created in the adjacent tissue. (C) The buccal mucosal flap isused to cover the hinged flap and exposed palatine bone. (Color version of figure is available online.)

AnThveipa

Reconstruction of the hard and soft palate 67gularis Oris Axial Pattern Buccal Flapis axial pattern flap is based on the angularis oris artery and

Figure 7 (A) Incisions are created in the nasal and oral side oare created, one based on the oral side of the defect and thsutured in three layers with sutures in the nasal mucosa, paextended through the palatine muscles to decrease tensionn. It may be used to repair defects in the hard and softlate to the contralateral dental arcade, or to the distal gin-

vassural margin of the canine tooth or beyond, depending onll conformation.1 Advantages of the flap include its highly

site sides of the defect in the soft palate. (B) Two flapson the nasal side of the defect. (C) The soft palate isuscles, and oral mucosa. Releasing incisions may be

e repair.givsku

f oppoe otherlatine mon thcular and robust character, high degree of mobility, and aface of tough buccal mucosa.1

couto maof

theis rartizatiothelarpomucrecauchpocramousisou

68 R.K. SivacolundhuThe angularis oris artery is a branch of the facial artery andrses from near the cranial border of the masseter musclethe ipsilateral commissure of the mouth (Fig. 9). A pulsey be palpated in the labial tissue caudal to the commissurethe lips.1

An incision is made through the skin over the artery fromcommissure of the lips and extending caudally. The skineflected dorsally and ventrally to expose the angularis orisery and vein. If the artery is difficult to identify via visual-tion or palpation, it may be identified via transillumina-n of the tissue. A full-thickness incision is made throughremaining cheek tissue, dorsal and ventral to the angu-

is oris vessels, extending to the caudal extent of the buccaluch, thus creating a rectangular flap attached by buccalcosa at the caudal buccal margin. An island flap may beated by incising through the buccal mucosal at thedal extent of the buccal pouch and undermining theeek tissue. The dissection is continued caudally to aint at which the angularis oris vessels enter under thenioventral border of the masseter muscle.1 The flap isbilized into the defect and sutured in a single layering simple interrupted sutures1 (Fig. 10). The donor site

Figure 8 (A) A buccal mucosal transposition flap is createdand sutured to reconstruct large defects extending as far ausing simple interrupted sutures. (Color version of figurewith the base at the palatoglossal arch. (B) It may be rotateds the caudal edge of the soft palate. The donor site is closedis available online.)closed in three layers. The oral mucosa and subcutane-s tissue are closed separately using simple continuous

Figuwitre 9 The angularis oris artery branches from the facial artery andhin the labial tissue extends to the commissure of the mouth.

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flap, suturing flaps to freshly incised tissue edges, avoidingplacement of suture lines over the defect, and gentle tissuehandling.

References1. Bryant KJ, Moore K, McAnulty JF: Angularis oris axial pattern buccal

flap for reconstruction of recurrent fistulae of the palate. Vet Surg32:113-119, 2003

2.

3.

4.

5.

6.

7.

8.9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

Figucaume

Reconstruction of the hard and soft palate 69tures. The skin is closed routinely. A single 2/0 nylonrtical mattress suture is placed at the commissure of thes to protect the closure against tension when the mouthopened.1

The superficial cervical axial pattern skin flap has also beendified for oral reconstruction. It requires the use of aeumatic dermatome and is performed as a staged proce-re.9

ostoperative Careravenous fluids should be provided until the animal ising and drinking, usually within 24 to 48 hours of surgery.ft food is given for 2 to 4 weeks, and chewing on hardjects must be prevented. An Elizabethan collar should bed if the animal is pawing at the mouth. Antibiotics are notuired in most cases, although they may be used for casessevere rhinitis. Healing should be evaluated 2 to 4 weekser surgery.20 Use of a feeding tube should be consideredlowing major repairs.

ummaryfects of the hard and soft palate may result from a numberdifferent etiologies. It is possible to primarily repair thejority of defects, although a variety of techniques mayed to be combined for repair of large defects. An under-nding of the different reconstructive techniques availablemperative to plan the surgical procedure. Complicationsminimized by adhering to basic principles of palate sur-y, which include making flaps slightly larger than thefects to be reconstructed, maintaining vascularity to the

re 10 An angularis oris axial pattern flap is shown rotated in to adal hard palate defect, following resection of a large palatelanoma.Degner DA, Lanz OI, Walshaw R: Myoperitoneal microvascular freeflaps in dogs: an anatomical study and a clinical case report. Vet Surg25:463-470, 1996Harvey CE: Palate defects in dogs and cats. Compend Contin EducPract Vet 9:404-418, 1987Luskin IR: Reconstruction of oral defects using mucogingival pedicleflaps. Clin Tech Small Anim Pract 15:251-259, 2000Sager M, Nefen S: Use of buccal mucosal flaps for the correction ofcongenital soft palate defects in three dogs. Vet Surg 27:358-363,1998Griffiths LG, Sullivan M: Bilateral overlapping mucosal single-pedicleflaps for correction of soft palate defects. J Am Anim Hosp Assoc 37:183-186, 2001Howard DR, Davis DG, Merkley DF, et al: Mucoperiosteal flap tech-nique for cleft palate repair in dogs. J Am Vet Med Assoc 165:352-354,1974Knight G: Surgical closure of the cleft palate. Vet Rec 70:680-681, 1958Dundas JM, Fowler JD, Shmon CL, et al: Modification of the superficialcervical axial pattern skin flap for oral reconstruction. Vet Surg 34:206-213, 2005Robertson JJ, Dean PW: Repair of a traumatically induced oronasalfistula in a cat with a rostral tongue flap. Vet Surg 16:164-166, 1987Coles BH, Underwood LC: Repair of the traumatic oronasal fistula inthe cat with a prosthetic acrylic implant. Vet Rec 122:359-360, 1988Hobson HP, Heller RA, Wilson JB: Use of a removable maxillary appli-ance to correct a palatal defect in a dog. Vet Med Small Anim Clin66:1085-1087, 1971Smith MM, Rockhill AD: Prosthodontic appliance for repair of an oro-nasal fistula in a cat. J Am Vet Med Assoc 208:1410-1412, 1996Thoday KL, Charlton DA, Graham-Jones O, et al: The successful use ofa prosthesis in the correction of a palatal defect in a dog. J Small AnimPract 16:487-494, 1975Banks TA, Straw RC: Multilobular osteochondrosarcoma of the hardpalate in a dog. Aust Vet J 82:409-412, 2004Beck JA, Strizek AA: Full-thickness resection of the hard palate fortreatment of osteosarcoma in a dog. Aust Vet J 77:163-165, 1999Ellison GW, Mulligan TW, Fagan DA, et al: A double reposition flaptechnique for repair of recurrent oronasal fistulas in dogs. J Am AnimHosp Assoc 22:803-808, 1986Ishikawa Y, Goris RC, Nagaoka K: Use of a cortico-cancellous bonegraft in the repair of a cleft palate in a dog. Vet Surg 23:201-205, 1994Nelson AW: Cleft palate, in Slatter D (ed): Textbook of Small AnimalSurgery, vol 1 (ed 3). Philadelphia, PA, Saunders, 2003, pp 814-823Hedlund CS: Surgery of the oral cavity and oropharynx, in Fossum TW(ed): Small Animal Surgery (ed 2). St. Louis, MO, Mosby, 2002, pp274-307Salisbury SK: Maxillectomy and mandibulectomy, in Slatter D (ed):Textbook of Small Animal Surgery, vol 1 (ed 3). Philadelphia, PA,Saunders, 2003, pp 561-572Hammer DL, Sacks M: Surgical closure of cleft soft palate in a dog. J AmVet Med Assoc 158:342-345, 1971Headrick JF, McAnulty JF: Reconstruction of a bilateral hypoplastic softpalate in a cat. J Am Anim Hosp Assoc 40:86-90, 2004

Use of Local and Axial Pattern Flaps for Reconstruction of the Hard and Soft PalateLocal Flaps for the Hard PalateMucoperiosteal Flaps and Releasing IncisionsLocal Flaps from the Soft PalateBuccal Mucosal FlapsDouble Reposition Flap

Local Flaps for the Soft PalateSoft Palate Mucosal Flaps and Releasing IncisionsBuccal Mucosal Flaps for the Soft PalatePharyngeal Wall Flaps

Axial Pattern and Distant FlapsAngularis Oris Axial Pattern Buccal Flap

Postoperative CareSummaryReferences