Bilateral Small Radial Forearm Flaps for the Reconstruction of Buccal Mucosa after Surgical Release of Submucosal Fibrosis: A New, Reliable Approach

Abstract

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and often severely limiting mouth opening. Previous surgical treatments have been disappointing. This article introduces a new surgical approach: reconstructing the bilateral buccal mucosa with two small radial forearm flaps. The surgical method includes the complete surgical release of fibrotic buccal mucosa and, if necessary, a bilateral coronoidectomy and temporalis muscle myotomy. From 1997 to 1999, 15 patients with moderate-to-severe trismus received reconstructive surgery, for a total of 30 small radial forearm flaps after surgical release. The flap size was between 1.5 x 5 and 2.5 x 7 cm. All donor sites were directly closed, and all flaps survived completely, except for one with partial necrosis. Six flaps required minor revisions because of size redundancy. Two patients developed buccal cancer in the area of reconstruction. At an average of 12 months' follow-up, the inter-incisal distance averaged 33 mm, an increase of 17 mm compared with the preoperative value. The donor-site morbidity was minimal, except in one heavy smoker who developed dry gangrene of his fingertips. The use of two small free forearm flaps for buccal mucosa reconstruction allows more radical release of fibrotic tissue. Coronoidectomy and temporal muscle myotomy further contribute to the effect of trismus release. The combined effects of this approach have consistently given good results. An aggressive approach toward surgical treatment of this precancerous lesion also facilitates the detection of cancer at an early stage.

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

“…Simple excision of the fibrous bands can increase scarring and exacerbate the condition. Results with split-thickness skin grafting, fresh human amnion or buccal fat pad grafts to cover the raw surfaces after resection of fibrous bands have been disappointing 10,14 . The incidence of shrinkage, contracture and infection of the grafts was high because oral conditions were poor and the symptoms usually recurred 10,14 .…”

“…1). Steps 1 and 2 are essentially the technique of WEI and coworkers, which has been well described in previous papers 2, 14 . In brief, the operation is performed by two teams simultaneously.…”

“…Surgery consists of releasing the fibrous bands by incising the mucosa down to the muscle layer from the angle of the mouth to the posterior pharyngeal area, and then resurfacing the raw areas with skin grafts, fresh human amnion, buccal fat pad grafts or various local flaps 4,[9][10][11]16 . In 2001, WEI et al were the first to use free flaps (bilateral small radial forearm flaps) for the reconstruction of buccal mucosa after surgical release of submucous fibrosis with great success 14 . They also emphasized the importance of coronoidotomy and masticatory muscle myotomy and postoperative rehabilitation in the prevention of relapse due to postoperative inactivity and scarring 2,7 .…”

Extended Nasolabial Flaps in the Management of Oral Submucous Fibrosis

“…5). The interincisal opening improved significantly from a mean (range) of 11 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) mm to 39 (23-48) mm at the end of 6 months and persisted without relapse for 1 years of follow up (Table 1).…”

“…This raw area heals by secondary intention and subsequently fibroses, leading to gradual relapse [7]. Bilateral radial forearm free flaps are hairy, 40% of patients require secondary debulking procedures, and the facilities for free tissue transfer are not universally available [8]. Canniff and Harvey [9] recommended temporal myotomy or coronoidectomy to release severe trismus caused by the atrophic changes in the tendon of temporalis muscle secondary to the disease.…”