Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft a new technique

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1 British Journal of Plastic Surgery (2005) 58, Release of oral submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft a new technique N.J. Mokal a, *, R.S. Raje b, S.V. Ranade a, J.S. Rajendra Prasad b, R.L. Thatte a a The Bhatia General Hospital, Tardeo Road, Tardeo, Mumbai , India b Plastic Reconstructive and Microsurgical Service, Tata Memorial Hospital, Dr Ernest Borges Marg, Parel, Mumbai , India Received 30 September 2004; accepted 28 April 2005 KEYWORDS Submucous; Fibrosis; Temporal; Fascia Summary Long standing oral submucous fibrosis is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. This article introduces a new technique of release of submucous fibrosis and reconstruction using superficial temporal fascia flap and split skin graft. The surgical technique involves a pre-auricular incision extending into the temporal region with dissection carried out in the sub follicular plane to develop the superficial temporal fascia flap to its maximum extent. The masseter muscle origin is released from the zygomatic arch and the temporalis muscle insertion is released from the coronoid process through an external approach. The entire fibrosed mucosa is released intraorally to create a mucomuscular defect thus achieving full mouth opening. The superficial temporal fascia flap is then brought in and sutured to the intraoral defect, which is then covered with a split thickness skin graft. This procedure is performed bilaterally. A total of five patients were treated with this new technique and all of them showed good mouth opening in long term follow up. There was no donor site morbidity. The incision line is well hidden in the hair bearing area. A well vascularised superficial temporal fascia flap brings in good blood supply to the area of affected muscle and mucosa to improve its function. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. * Corresponding author. Address: Charak-12, Mumbai Port Trust Hospital Campus, Nadkarni Park, Wadala, Mumbai , India. Tel.: C address: nitinmokal@vsnl.net (N.J. Mokal). Oral submucous fibrosis is commonly seen in the Indian subcontinent. The condition has a multifactorial origin but is commonly associated with chewing of areca nut (betal nut) habitually. This condition was first described by Schwartz in S /$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /j.bjps

2 1056 The role of Arecoline and Tannis of areca nut causing juxtaepithelial hyalinisation and muscle fibrosis is well described in the literature. 2 The clinical features such as excessive salivation, absent gustatory sensation and limitation of mouth opening leads to difficulty in chewing, swallowing, articulation and poor oral hygiene (Figs. 1 and 2). The oral mucosa appears pale, dense, with vertical fibrotic bands extending to the anterior tonsillar pillars. These patients are grouped according to the severity of the disease. 3 Nonsurgical measures like local steroids, hyaluronidase injections, vitamin supplements and jaw opening exercises have poor results. 4 Simple release of fibrosis and skin grafting showed recurrence due to scarring and graft contraction. 5,6 Use of bilateral tongue flaps is a very damaging procedure and requires flap division at a second stage. Nasolabial flaps are small compared to the defect. 7 Island palatal mucoperiosteal flap based on the greater palatine artery is possible only in some cases. 3 Bilateral radial artery forearm free flap is bulky and hair bearing. 8 The present technique involves release of oral submucous fibrosis which involves release of masseter and temporalis muscle externally and oral mucosal bands internally. The anatomy as well as the use of superficial temporal Figure 2 opening. N.J. Mokal et al. Pre-operative picture with restricted mouth fascia for head neck reconstruction is well reported in literature Reconstruction of this mucomuscular defect using superficial temporal fascia and skin graft is discussed. Figure 1 opening. Pre-operative picture with restricted mouth Surgical technique Elective tracheostomy is performed under local anaesthesia. Infiltration of the incision from the pre-auricular region extending to the temporal region is done 10 min before the incision. Dissection is performed in the sub follicular plane to develop the superficial temporal fascia flap to its maximum limit (Fig. 3). Sub periosteal dissection is performed over the zygomatic arch and the zygomatico maxillary area. The origin of the masseter muscle is released completely from the zygomatic arch and the zygomatic process of the maxillary bone. This allows partial release of the fibrosis (Fig. 4). The dissection is carried along the coronoid process. Insertion of the temporalis muscle is released from the coronoid process and the anterior border of the ramus of the mandible (Fig. 5). An intraoral incision is made to release the mucosa, buccinator muscle, and pterygomandibular raphe. This procedure is repeated on the opposite side allowing complete release of submucous fibrosis with full mouth

3 Release of oral submucous fibrosis and reconstruction 1057 Figure 3 Dissected superficial temporal fascia flap to its maximum extent. opening (Fig. 6). This release creates a big mucomuscular defect. A superficial temporal fascia flap is elevated from the pericranium and the deep temporal fascia. The flap is pedicled on the Figure 5 insertion. Release of temporalis muscle from its Figure 4 Release of masseter muscle from its origin. Figure 6 Full mouth opening after bilateral release.

4 1058 N.J. Mokal et al. superficial temporal vessels and turned over the zygomatic arch and brought intraorally to fill in the defect (Fig. 7). Split skin graft harvested from the thigh is sutured over the flap intraorally, covering the defect and is immobilised with a tie over dressing. The tie over dressing is removed on the fifth post-operative day. All five cases in this series showed full survival of the graft and flap (Fig. 8). A temporary tracheostomy tube was removed on the seventh post-operative day. Results A total of five patients with severe submucous fibrosis were treated with this technique. Mouth opening was 0 5 mm in all these patients preoperatively. Inter incisor distance of 45 mm was achieved intra operatively on release of mucosa, masseter origin and temporalis insertion. All patients had complete survival of flap and full take of the skin graft (Figs. 9 11). Discussion Figure 8 day. Full take of the graft on 5th post-operative debilitating disease. It presents with difficulty in mouth opening with poor oral hygiene and its complications. The aim of treatment for this condition is to provide good release of fibrosis and provide long term results in terms of mouth opening. Conservative treatment with local Long standing oral sub mucous fibrosis is a Figure 7 Superficial temporal fascia brought into the muco-muscular defect. Figure 9 Well matured graft with long term result of full mouth opening.

5 Release of oral submucous fibrosis and reconstruction 1059 Figure 10 Long term post-operative results. steroids, hyaluronidase injections and physiotherapy are not beneficial in advanced cases. 4 Surgery is required in all advanced cases. 3 Release of fibrosis and split skin grafting have a high recurrence rate due to graft shrinkage. 5,6 Use of island palatal flap has limitations such as its involvement with fibrosis and second molar tooth extraction is required for flap cover without tension. 3 Bilateral palatal flaps leave a large raw area on palatal bone. Some times the defect created may be large and local flaps may not be able to cover the entire defect. Nasolabial flap is too short to cover the defect and causes visible scarring on the face and requires division at second stage. 7 Bilateral free radial artery forearm free flaps 8 require microvascular expertise, the flaps are hairy and 40% of patients require secondary debulking procedures. Extraction of the third molar tooth is required to avoid flap inclination between teeth. This new technique releases strong muscles of mouth closure such as masseter from its origin and temporalis from its insertion. Intra oral release of the mucosa, pterygomandibular raphe and buccinator muscle leaves a mucomuscular defect. Well vascularised superficial temporal fascia flap 9 12 brings good blood supply for the fibrosed muscles and mucosa and provides a healthy bed for the skin graft. This procedure has its foundation on anatomical landmarks and physiological facts and is an effective method of treating oral sub mucous fibrosis. References Figure 11 Long term post-operative results. 1. Schwartz J. Atrophia idiopathica mucosa oris. Presented at the 11th International Dental Congress, London; Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral submucous fibrosis. Relationship to risk factors associated with oral cancer. Cancer 1992;69(8): Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgical management: report of 100 cases. Int J Oral Maxillofac Surg 1995;24(6): Gupta D, Sharma SC. Oral submucous fibrosis: a new treatment regimen. J Oral Maxillofac Surg 1988;46(10): Borle RM, Borle SR. Management of oral submucous fibrosis: a conservative approach. J Oral Maxillofac Surg 1991;49(8): Morawetz G, Katsikeris N, Weinberg S, Listrom R. Oral submucous fibrosis. Int J Oral Maxillofac Surg 1987;16(5): Kavarana NM, Bhathena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987;40(4): Wei FC, Chang YM, Kildal M, Tsang WS, Chen HC. Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new reliable approach. Plast Reconstr Surg 2001;107(7):

6 Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C. The fascial planes of the temple and face: an enbloc anatomical study and a plea for consistency. Br J Plast Surg 2003;56(7): Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical anatomy and blood supply of the fascial layers of the temporal region. Plast Reconstr Surg 1986;77(1): N.J. Mokal et al. 11. Tellioglu AT, Tekdemir I, Erdemli EA, Tuccar E, Ulusoy G. Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential clinical applications. Plast Reconstr Surg 2000;105(1): Fukuta K, Jackson IT, Collares MV, Har-Shai Y, Namiki Y. The volume limitation of the galeal temporalis flap in facial augmentation. Br J Plast Surg 1991;44(4):281 4.