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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 151-153

Nasolabial island flap for management of post osteo-odonto-keratoprosthesis oroantral fistula


1 Department of Plastic Surgery, B. J. Government Medical College, Sassoon Hospital, Pune, Maharashtra, India
2 Department of Burns and Plastic Surgery, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
3 Super Speciality Dental Clinic, Peru Gate, Pune, Maharashtra, India

Date of Submission17-Oct-2020
Date of Acceptance10-Dec-2020
Date of Web Publication7-Jun-2021

Correspondence Address:
Dr. Nikhil Panse
Department of Plastic Surgery, B. J. Government Medical College, Sassoon Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_39_20

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  Abstract 


Osteo-odonto-keratoprosthesis (OOKP) is a procedure that is beneficial to patients with end-stage ocular disease, which is not amenable to corneal transplantation. It involves the harvest of tooth lamina and implantation of lamina cortex into the eye. The oroantral fistula (OAF) is one of the most disastrous complications of this procedure. The complication of an OAF during the harvest of a molar for an OOKP procedure can be prevented by applying a sound surgical technique. However, in case an OAF develops, it can be managed by a variety of options depending on the dimensions of the defect. In this report, we present the use of a nasolabial flap along with an upper sulcus flap for coverage of an OAF after undergoing an OOKP procedure. Measures to avoid this disastrous complication have also been discussed.

Keywords: Nasoantral fistula, nasolabial flap, osteo-odonto-keratoprosthesis


How to cite this article:
Panse N, Narsimhan A, Dadhe P. Nasolabial island flap for management of post osteo-odonto-keratoprosthesis oroantral fistula. J Cleft Lip Palate Craniofac Anomal 2021;8:151-3

How to cite this URL:
Panse N, Narsimhan A, Dadhe P. Nasolabial island flap for management of post osteo-odonto-keratoprosthesis oroantral fistula. J Cleft Lip Palate Craniofac Anomal [serial online] 2021 [cited 2021 Jun 18];8:151-3. Available from: https://www.jclpca.org/text.asp?2021/8/2/151/317786




  Introduction Top


Osteo-odonto-keratoprosthesis (OOKP) is a procedure that is beneficial to patients with end-stage ocular disease, which is not amenable to corneal transplantation. A multidisciplinary approach is required, with the involvement of both ophthalmologists and maxillofacial surgeons. It is a two-staged procedure, with Stage 1 involving harvesting a tooth for preparation of the OOKP lamina and Stage 2 involving implantation of lamina complex into the eye.[1] The oroantral fistula (OAF) remains one of the most disastrous complications of this procedure and can be managed by a variety of methods such as buccal advancement flaps, palatal rotation and transposition flaps, tongue flaps, and nasolabial flaps.[2],[3] In this report, we present the use of a nasolabial flap along with an upper sulcus flap for coverage of an OAF after undergoing an OOKP procedure. Measures to avoid this disastrous complication have also been discussed.


  Case Report Top


A 20-year-old female presented to us with an OAF. Her upper first molar on the left side was harvested for an OOKP procedure before a year, and the defect had persisted in the postoperative period. The defect was full thickness and around 1.5 cm × 1.5 cm in dimensions [Figure 1]. There was no concomitant maxillary sinus infection at the time of presentation. There were recurrent episodes of sinusitis because of constant exposure of the antrum to the food particles and contaminants in the oral cavity and lack of hygiene on the part of the patient.
Figure 1: Oroantral fistula

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The coverage of the defect necessitated two flaps: one for lining and one for cover. The turndown upper gingivobuccal (GB) sulcus flap was planned for the lining, and the superiorly based nasolabial flap was planned for the cover. The procedure began with freshening of the raw areas and creating two surfaces to suture both the flaps. The turndown flap from the upper GB sulcus was harvested as a full-thickness mucosal flap and sutured to the edge of the defect. The nasolabial flap was islanded and raised in the subcutaneous plane above Superficial Musculo Aponeurotic System (SMAS) with an adipofascial tail till the pivot point at the level of nasal ala. The perforators of the nasolabial artery were identified and preserved. The nasolabial flap was tunneled into the defect through the upper GB sulcus and sutured over the defect. The donor sites of both the flaps were closed primarily [Figure 2].
Figure 2: Healed oroantral fistula, which was covered using nasolabial flap

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Postoperatively, clear liquids were initiated, followed by liquid diet. Oral hygiene was maintained. Scar care in the form of sun protection, massage, and emollients was initiated in the postoperative period for the scar over the nasolabial area. At 1-year follow-up, the patient had a totally healed OAF with no episodes of sinusitis. The scar over the nasolabial area was well settled, and we had a satisfied patient in terms of outcomes related to the OAF [Figure 3].
Figure 3: Well-settled donor site

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  Discussion Top


OOKP is the procedure of choice for restoring sight in patients with end-stage ocular disease, where cornea transplantation is not an option.[1]

OAF is probably the most difficult complication of OOKP procedure to manage.[2] The OAF is a pathological communication between the oral cavity and the maxillary sinus. These kinds of communications arise mainly after extraction of posterior maxillary teeth due to the close anatomical relationship between the roots of the molar and premolar teeth and the sinus floor, which are separated by a thin bony lamella.[3],[4]

The complication of an OAF during the harvest of a molar for an OOKP procedure can be prevented by applying a sound surgical technique. The incision is marked surrounding the selected tooth and is deepened to the bone. The mucoperiosteal flaps are elevated from the adjacent teeth so as to facilitate comfortable closure after the harvest. The bone cuts are made along the sides of the tooth and below the chosen tooth with a fine saw, under constant irrigation to minimize any thermal injury to the lamina. Due care is taken to prevent injury to the thin lamella between the roots of the molars and the sinus floor. The mucosal flaps from the adjacent area are mobilized to cover the resulting alveolar defect. The residual exposed bone mucosalizes very rapidly.[5]

Complications at the site of surgery occur mostly due to poor healing resulting in exposure of roots of adjacent teeth and damage to the adjacent maxillary sinus. Should the OAF remain patent, an obturator is needed to prevent nasal reflux until formal closure can be carried out.[5] Closure of the fistula is important to avoid food and saliva contamination that could lead to bacterial infection, impaired healing, and chronic sinusitis. The choice of the appropriate therapy must take into consideration the width, epithelialization, and presence or absence of infections. Defects <3 mm in width and without epithelialization might heal spontaneously in the absence of infections.[4] Communications wider than 5 mm require the use of rotating and sliding flaps to provide closure.[4] However, the defects which are still larger might need regional tissue from the face like the nasolabial flap, especially if the palatal tissues are already scarred due to previous surgeries.

The nasolabial flap is one of the oldest techniques to replace orofacial soft-tissue defects.[6] Sushruta, an Indian surgeon in 600 BC, described a soft-tissue flap very similar to what we know today as “nasolabial flap.”[7] The ease of surgery, fairly constant anatomy, versatility in the arc of rotation, probability of carrying out the procedure under local anesthesia in comorbid patients, and inconspicuous donor site scar are the advantages of this flap.[8] The flap is commonly designed lateral to the nasolabial fold with the medial limit of the flap 2–3 mm lateral to this fold.[9] In the superiorly based nasolabial flap, the base of the flap is near the ala and the apex is in line with the oral commissure.[10]

Most commonly, the islanded nasolabial flap with the subcutaneous pedicle is used for intraoral reconstruction.[11] The de-epithelialization of the skin near the base is necessary to prevent iatrogenic dermoid cyst formation when this flap is passed through the transbuccal tunnel to reach the oral cavity.[12]

Being a large defect with need of two flaps, we used the upper GB sulcus flap for lining and the superiorly based subcutaneous pedicled nasolabial flap for the coverage of the defect.

We would like to conclude by highlighting that OAF after OOKP procedure can be prevented by sound surgical techniques. In case a large OAF persists, the superiorly based islanded nasolabial flap is a good choice for reconstruction in terms of ease of surgery, accessibility, and an esthetically favorable donor site scar.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wong HS, Then KY, Ramli R. Osteo-odonto-keratoprosthesis for end-stage cornea blindness. Med J Malaysia 2011;66:369-70.  Back to cited text no. 1
    
2.
Tay AB, Tan DT, Lye KW, Theng J, Parthasarathy A, Por YM. Osteo-odonto-keratoprosthesis surgery: A combined ocular-oral procedure for ocular blindness. Int J Oral Maxillofac Surg 2007;36:807-13.  Back to cited text no. 2
    
3.
Yilmaz T, Suslu AE, Gursel B. Treatment of oroantral fistula: Experience with 27 cases. In: American Journal of Otolaryngology-Head and Neck Medicine and Surgery. Vol. 24: W.B. Saunders; 2003. p. 221-3. Available from: http://www.sciencedirect.com/science/article/pii/S0196070903000279. [Last accessed on 2018 Jan 19].  Back to cited text no. 3
    
4.
Enrico Borgonovo A. Surgical options in oroantral fistula treatment. Open Dent J 2012;6:94-8.  Back to cited text no. 4
    
5.
Liu C, Paul B, Tandon R, Lee E, Fong K, Mavrikakis I, et al. The osteo-odonto-keratoprosthesis (OOKP). Semin Ophthalmol. 2005;20:113-28. doi: 10.1080/08820530590931386. PMID: 16020351.  Back to cited text no. 5
    
6.
Gewirtz HS, Eilber FR, Zarem HA. Use of the nasolabial flap for reconstruction of the floor of the mouth. Am J Surg 1978;136:508-11.  Back to cited text no. 6
    
7.
Ellabban MA, Van Niekerk WJ, Shoaib T. Sutures to mark the exact site of division of the two-stage nasolabial flap for floor-of-mouth reconstruction. J Plast Reconstr Aesthet Surg Elsevier 2008;61:217-8.  Back to cited text no. 7
    
8.
Navarro Cuellar C, Caicoya SJ, Acero Sanz JJ, Navarro Cuellar I, Muela CM, Navarro Vila C. Mandibular reconstruction with iliac crest free flap, nasolabial flap, and osseointegrated implants. J Oral Maxillofac Surg 2014;72:1226.e1-15.  Back to cited text no. 8
    
9.
Bi H, Xing X, Li J. Nasolabial-alar crease. Ann Plast Surg 2014;73:520-4.  Back to cited text no. 9
    
10.
Borle RM, Nimonkar PV, Rajan R. Extended nasolabial flaps in the management of oral submucous fibrosis. Br J Oral Maxillofac Surg 2009;47:382-5.  Back to cited text no. 10
    
11.
Rahpeyma A, Khajehahmadi S. Treatment of a unilateral Tessier number 4 facial cleft in an adult: Role of nasolabial V-Y advancement flap. Br J Oral Maxillofac Surg 2015;53:99-101.  Back to cited text no. 11
    
12.
Elliott RA. Use of nasolabial skin flap to cover intraoral defects. Plast Reconstr Surg 1976;58:201-5.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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