technique

1. Palatal island flap
Jameel kifayatullah

2. Flap landmarks
Important flap landmarks include
(1) palatal gingival crest
(2) greater palatal foremen (palatal to the
maxillary second molar)
(3) boundary between hard and soft palate, and
(4) hamular notch

3. technique
• The flap design begins after confirming the
dimensions of the defect. The anterior region
of the flap should be slightly wider than the
defect, and the length should allow for a
tension-free closure. A template can be
trimmed to the dimensions of the defect to
help with flap design, whereas the lateral
incision is made approximately 5 mm from the
gingival margins of the teeth, if present (Figs.
1 and 2).

4. technique
Reconstruction of a soft palate defect
using a palatal rotation flap.
. Outlining the margins of the flap

5. Technique
• After full-thickness incisions are made through
the mucoperiosteum, flap dissection proceeds
from anterior to posterior, working toward the
neurovascular bundle ipsilateral side, and
requires ligation of the contralateral
neurovascular bundle in addition to the incisal
canal

6. Flap elevation begins at the side
contralateral to the pedicle

7. Technique
• After raising the flap, the neurovascular bundle is
dissected carefully from the undersurface of the
proximal portion of the flap. The dissection
continues until the distal portion of the flap being
used for the defect is encountered. Finally, the
mucosa is transected above the bundle, allowing
for and leaving the remaining distal end of the
mucosa attached to the bundle. The bundle may
be tunneled under adjacent mucosa before
reaching the intended defect; however, care must
be taken to ensure there is no compression

8. Technique
• Alternatively, the pedicle can cross over the
normal palatal tissue before reaching the
reconstruction site. This alternative requires
second-stage surgery, which can be
undertaken approximately 3 weeks later

9. Flap sutured in place

10. technique
• After the defect closure, the denuded bone
may be addressed using either iodoform gauze
sutured in place or a preformed stent. When
using a stent, it is important to ensure that
there is no pedicle compression. Re-
epithelialization may take between 3 and 5
weeks, although in smokers this may be
delayed to 6 to 8 weeks

11. Random rotation-advancement flap
• Alternatively, the palatal flap can be raised as
a random rotation-advancement flap
• Mercer and Maccarthydemonstrated the
collateral blood supply between the greater
palatine artery and the ascending palatine
artery in the soft palate
• This anatomic basis allows one to sacrifice the
greater palatine artery without jeopardizing
the vitality of the flap

12. Random rotation-advancement flap
• The flap is raised similarly to its axial counterpart;
however, no incision is made in the proximal end
of this flap, and the medial aspect of the flap
does not cross the midline (2–3 mm away from
the midline)
• This modification of the flap has a limited arc of
rotation; therefore, it is more commonly used for
closure of oral-antral or oral-nasal fistulas
• the palatal flap can close the communication in a
single layer

13. PALATAL ROTATION ADVANCEMENT
FLAP
• Illustrations
demonstrate the
harvesting and insetting
of palatal rotation-
advancement flap for
closure of oral-antral
communication

14. Complications
• Flap failure(Low in axial pattern flap high in
random pattern flap)
• intraoperative bleeding caused by injury to
the greater palatine vessels, or in some cases,
a secondary major vessel, which came out of
the minor palatine

15. INDICATIONS
• Axial flap
• oropharyngeal defects, which include the
retromolar trigone,soft palate, tonsillar
fossa,cheek, posterior one-third of the floor of
the mouth,and oro- nasal and oroantral fistula
closures
• With regard to defect size, up to 75% of the
palatal mucosa may be used, allowing defects
of up to 16 cm2 to be closed

16. INDICATIONS
random flap
• the palatal flap is more suitable for oral-
antral/nasal communication. Because of the
less reliable vascular blood supply, a palatal
flap harvested in a random pattern should not
cross the midline and maintain the
length/width ratio at less than 2.4:1

17. CONTRAINDICATIONS
• The flap is contraindicated whenever there is
concern for a compromised blood supply. This
may result from a history of ipsilateral internal
carotid artery ligation, surgeries with adjacent
incisions, or radiation therapy, which have
been shown to increase the risk of flap failure