Speech and swallowing following radial forearm flap reconstruction of major soft palate defects

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Summary

Velopharyngeal function is often compromised by the resection and reconstruction of oropharyngeal and palatal tumours. While free tissue transfer has improved the outcomes of head and neck reconstruction. In general, palatal reconstruction remains a challenge.

Velopharyngeal function was analysed in eight patients following microsurgical reconstruction of defects of between 50 and 100% of the soft palate. The radial forearm fasciocutaneous free flap was used in all cases. The outcome of reconstruction was analysed by patient questionnaire and with standardised tests of speech and swallowing function. Velopharyngeal function post-operatively ranged from poor to near normal. Poor function appeared due to the loss of active elevation and contracture of the reconstructed palate producing failure of velopharyngeal closure during swallowing and speech.

The results emphasise the limitations of reconstruction of a dynamic structure such as the soft palate with the static fold of skin and soft tissue produced by a fasciocutaneous flap. The relatively poor results obtained suggest that an anatomical approach to soft palate reconstruction is inadequate and reduction of the calibre of the velopharyngeal aperture is required to compensate for the lack of mobility in the reconstructed palate.

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Patients and methods

Patients who had undergone soft palate resection and free flap reconstruction during the 5-year period between January 1995 and January 2000 were identified. The patients were included in the study if the extent of resection of the soft palate was at least 50% and they were alive and free of disease at the time of review. The patient records were reviewed for operation details and then the patients themselves reviewed for evaluation of function.

Results

There were two peri-operative complications. One patient returned to theatre for successful revision of the arterial anastomosis and one patient had a neck wound dehiscence, which healed with dressings alone. One patient did not tolerate the post-operative radiotherapy and received a limited dose of 26 Grey (Gy). The other three patients treated with post-operative radiotherapy received a full dose of 60 Gy within 3 months of surgery.

All eight patients who identified were reviewed. The average

Discussion

Reconstruction of the soft palate should aim to restore speech and swallowing. For significant palatal defects, the pliability and thinness of the radial forearm flap are advantageous in matching the three-dimensional conformation of the defect and it has been a popular choice in soft palate reconstruction.9, 10, 13, 14, 15 The technique of inset of the forearm flap has varied in published reports. In this series, the forearm flaps were inset aiming to restore the normal palatal anatomy. The

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Paper presented at the Royal Australasian College of Surgeons Annual Scientific Congress, May 2000 and the annual meeting of the Australia and New Zealand Head and Neck Society, November 2001.

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