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DENTAL SCIENCE - CASE REPORT
Year : 2015  |  Volume : 7  |  Issue : 6  |  Page : 708-711  

Platysma myocutaneous flap for reconstruction of intraoral defects following excision of oral sub mucous fibrosis: A report of 10 cases


Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry, India

Date of Submission28-Apr-2015
Date of Decision28-Apr-2015
Date of Acceptance22-May-2015
Date of Web Publication1-Sep-2015

Correspondence Address:
Sathyanarayanan Ramanujam
Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.163485

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   Abstract 

Various surgical procedures are available for treating oral submucous fibrosis, but all of them have their inherent drawbacks. The superiorly based platysma myocutaneous flap is a common reconstruction option for intraoral defects followed after excision of fibrous bands in oral submucous fibrosis. The superiorly based flap has an excellent blood supply, but less efficient venous drainage when compared with posteriorly based flap. We present our results of using a superiorly based flap in the treatment of oral submucous fibrosis. Of 10 patients eight had no postoperative complications, one patient developed partial skin loss and other developed venous congestion which was managed conservatively.

Keywords: Intraoral reconstruction, oral submucous fibrosis, platysma myocutaneous flap


How to cite this article:
Ramanujam S, Venkatachalam S, Subramaniyan M, Subramaniyan D. Platysma myocutaneous flap for reconstruction of intraoral defects following excision of oral sub mucous fibrosis: A report of 10 cases. J Pharm Bioall Sci 2015;7, Suppl S2:708-11

How to cite this URL:
Ramanujam S, Venkatachalam S, Subramaniyan M, Subramaniyan D. Platysma myocutaneous flap for reconstruction of intraoral defects following excision of oral sub mucous fibrosis: A report of 10 cases. J Pharm Bioall Sci [serial online] 2015 [cited 2019 Aug 23];7, Suppl S2:708-11. Available from: http://www.jpbsonline.org/text.asp?2015/7/6/708/163485

Platysma myocutaneous flap was first used for reconstruction of intraoral defects by Futrell in 1978. [1] After that, it has been used for reconstruction of various head and neck defects. Platysma myocutaneous flap is easy to harvest, thin and pliable, promoting three-dimensional reconstruction, and there is a limited donor site morbidity with primary closure of the neck. The advantages of platysma flap include good color match, easy access to the donor site in the same operative field with minimum morbidity of donor site, ease in closing the donor site primarily, and appropriate flap thickness for oral facial defects.

Oral submucous fibrosis is chronic and disabling disease with obscure etiology that affects the complete oral cavity occasionally with the pharynx, and rarely involving the larynx. It is characterized by blanching and stiffness of the oral mucosa, which causes progressive limitation of mouth opening and intolerance to hot and spicy food.

It's precancerous nature was described by Paymaster, [2] who recorded that, in one-third of patients with squamous cell carcinomas has a slow onset of growing. Murti et al.[3] reported the malignant transformation of oral submucous fibrosis.

The purpose of this report is to examine the experience and results obtained with the use of reconstruction of intraoral defects with platysma myocutaneous flap. When considering the complications that can occur when adopting this technique one has to include total or partial necrosis of skin island, fistula, dehiscence, hematoma, and cellulitis with rates ranging from 18% to 45%.(Cannon, et al., 1982). We think that platysma myocutaneous flap is a better option that an extended nasolabial flap in terms of extraoral facial scar for the management of oral submucous fibrosis. [4]


   Patients and Methods Top


Ten patients with oral submucous fibrosis were treated with superiorly based platysma myocutaneous flap. Six men and four women aged between 20 and 45 years were selected for this study after getting approval from Institutional Ethics Committee. Patients with oral submucous fibrosis falling in grades 3 and 4 were only selected for the study [Table 1].
Table 1: Number of patients with site of defect and complications

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   Surgical Technique Top


Superiorly based platysma myocutaneous flap was raised as described by Gupta [4] and used for reconstruction of the intraoral defects. With the neck hyperextended the proposed skin paddle was outlined on the ipsilateral neck, below the inferior border of the mandible [Figure 1]. The superior incision was made first and a plane superficial to the platysma muscle was dissected carefully cephalic to the inferior border of the mandible. A Skin incision was then made at the inferior line of the skin paddle, with additional exposure of the platysma muscle inferiorly. The platysma muscle was transected sharply at least 1 cm inferior to the edge of the skin paddle, and a subplatysmal plane of dissection developed just below the inferior border of the mandible. If the cervical branch of the facial nerve was to be incorporated, it was necessary to identify the nerve in the superficial layer of the deep cervical fascia and carefully dissect and preserve its proximal portion. Once the plane of dissection was fully developed, the platysma flap was transected vertically, anteriorly and posteriorly for full mobilization. The flap was introduced into the oral defect by creating an approximately sized soft tissue tunnel [Figure 2], [Figure 3] and [Figure 4]. The harvested flap was sutured to the defect which was created by the release of fibrous band [Figure 5]. The donor site was easily closed in layers to obtain an acceptable cosmetic result [Figure 6] and [Figure 7].
Figure 1: Marking platysma flap outline

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Figure 2: Submandibular incision to provide

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Figure 3: Harvesting the flap

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Figure 4: Rt flap in position

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Figure 5: Lateral thoracic flap in position

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Figure 6: Pre op mouth opening

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Figure 7: Post op mouth opening

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   Results Top


Eight patients encountered no problems during wound healing process. Partial skin loss occurred in one patient. In this patient, healing occurred by secondary intention, that result in an excellent re-epithelization because of the good blood supply from surrounding tissues. These complications need prolonged nasogastric nutrition for 15 days. In another patient, there was venous congestion in the early postoperative period but resolved after a maximum of 48 h. No flaps failed, and all patients had overall good cosmetic results. There was no donor site morbidity in any patient.


   Discussion Top


The goal of reconstruction is restoration form and function to allow a good quality of life. Oral and facial reconstruction after ablative surgery may be achieved in a variety of ways including skin grafts. Pedicled myocutaneous flaps and free flaps. Flap choice is related to the patient's condition and to the surgeons experience and ability.

We have found that superiorly based progressive massive fibrosis (PMF) can be used safely for reconstruction of intraoral defects following excision of fibrotic bands. The main complication of using a superiorly based PMF is venous congestion. In our study, one patient had venous congestion and the other had a partial skin loss. However, this was minimal and was managed by conservative measures only. The main venous drainage of platysma muscle is through the external jugular and submental veins. [5],[6] Utmost care should therefore be taken to preserve these vessels and this can be achieved easily.

The primary blood supply to PMF derives from submental artery which branches from a facial artery, additional blood supply comes inferiorly from the cervical transverse vessels, medially from thyroid vessels and laterally from occipital and postauricular vessels. This is a multiaxial blood supply as it has multiple anastomoses with ipsilateral and contralateral mental, labial and sublingual arteries. [7],[8]

In this study, platysma myocutaneous flap is avoided, if the muscle is thin because the blood supply to the skin island does not strictly depend on musculocutaneous perforating vessels, it is more of a fasciocutaneous with little muscle and it is technically difficult to set up.

Although various surgical options are available success rate varies with these procedures. Fibrous bands excision and propping the mouth open to allow secondary epithelization causes rebound fibrosis during healing. Split thickness skin grafting after excising fibrous bands results in high recurrence rate from contracture. Full thickness skin grafts rarely survive. Palatal island flap recommended by Khanna and Andrade [9] has its own limitations including involvement of donor tissue with limited reach of the flap and maxillary second molar needs to be removed to lower the defect so that flap is not under tension.

Tongue flap causes severe dysphagia, disarticulation, and risk of postoperative aspiration. Stability of tongue flap is questionable and dehiscence and uncontrolled tongue movements are the common postoperative complications. [10]

Buccal fat pad can also be used, but the anterior reach of it is inadequate and the region near canine cannot be covered, hence heals by secondary intention and subsequent fibrosis leads to gradual relapse. [11]

Temporal myotomy or coronoidectomy recommended by Caniff, et al.[12] to release severe trismus following atrophy of temporalis tendon secondary to the severity of submucous fibrosis.

We recommend the use of platysma muscle flap for reconstruction of intraoral defects after release of submucous fibrosis as the incision is some away from the face, the scars get hidden beneath collars and the patients are very comfortable.

 
   References Top

1.
Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978;136:504-7.  Back to cited text no. 1
[PUBMED]    
2.
Paymaster JC. Cancer of the buccal mucosa; a clinical study of 650 cases in Indian patients. Cancer 1956;9:431-5.  Back to cited text no. 2
[PUBMED]    
3.
Murti PR, Bhonsle RB, Pindborg JJ, Daftary DK, Gupta PC, Mehta FS. Malignant transformation rate in oral submucous fibrosis over a 17-year period. Community Dent Oral Epidemiol 1985;13:340-1.  Back to cited text no. 3
[PUBMED]    
4.
Gupta D, Sharma SC. Oral submucous fibrosis - A new treatment regimen. J Oral Maxillofac Surg 1988;46:830-3.  Back to cited text no. 4
    
5.
Agarwal A, Schneck CD, Kelley DJ. Venous drainage of the platysma myocutaneous flap. Otolaryngol Head Neck Surg 2004;130:357-9.  Back to cited text no. 5
    
6.
Uehara M, Helman JI, Lillie JH, Brooks SL. Blood supply to the platysma muscle flap: An anatomic study with clinical correlation. J Oral Maxillofac Surg 2001;59:642-6.  Back to cited text no. 6
    
7.
Coleman JJ 3 rd , Jurkiewicz MJ, Nahai F, Mathes SJ. The platysma musculocutaneous flap: Experience with 24 cases. Plast Reconstr Surg 1983;72:315-23.  Back to cited text no. 7
    
8.
Rabson JA, Hurwitz DJ, Futrell JW. The cutaneous blood supply of the neck: Relevance to incision planning and surgical reconstruction. Br J Plast Surg 1985;38:208-19.  Back to cited text no. 8
[PUBMED]    
9.
Khanna JN, Andrade NN. Oral submucous fibrosis: A new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995;24:433-9.  Back to cited text no. 9
    
10.
Kavarana NM, Bhathena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987;40:407-9.  Back to cited text no. 10
[PUBMED]    
11.
Yeh CJ. Application of the buccal fat pad to the surgical treatment of oral submucous fibrosis. Int J Oral Maxillofac Surg 1996;25:130-3.  Back to cited text no. 11
    
12.
Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: Its pathogenesis and management. Br Dent J 1986;160:429-34.  Back to cited text no. 12
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1]


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Journal of Surgical Oncology. 2017;
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