Palatal Arena

Description

The palatal flap (i.e., Arena flap) was originally described in 1977 (33). It is a muco-periosteal flap that can encompass up to 85% of the palatal mucosal based on a sin-

gle greater palatine artery (Fig. 26). The flap tissue can be rotated 180 degrees to cover defects in the posterior oral cavity.

Dissection involves incising through the mucoperiosteum along the perimeter of the hard palate and ligating the opposite greater palatine neurovascular bundle. The flap is raised with a periosteal elevating instrument and traverses the multiple fibrous tissue pegs (Sharpey's fibers). When the ipsilateral greater palatine foramen is reached, an additional 1 cm of length on the pedicle can be obtained by fracturing the hook of the hamulus.

Indications

The palatal flap is indicated to resurface defects up to 8 cm2 involving the lateral soft palate and retromolar trigone. It is useful when a defect is too small for a regional flap but is suitable for a local flap. The flap has been used in the past for closure of oroantral fistulas and in palate-lengthening procedures.

Neurovascular Anatomy

The vascular supply to the flap is the greater palatine artery and vein that emerge from the greater palatine foramen and course anterolaterally to the incisive foramen. There is excellent collateral flow across the midline of the palate, allowing the mucoperiosteum of the entire hard palate to be harvested based upon a single palatine artery.

Advantages

The advantages of the palatal flap include ease of harvest, excellent reliability, local source of tissue, avoidance of a skin graft and intraoral bolster, and minimal contracture over the reconstructed site.

Disadvantages

The major disadvantage in using the palatal flap is the prolonged re-epithelialization of the raw surface of the palate (2-3 months). This flap should not be used in children because of the possibility of altered midface growth.

REFERENCES

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4. Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for total nasal reconstruction. Clin Plast Surg 1983; 10:635-647. ยง

5. Manchot C. Die Hautarterien des Menschlichen Koerpers. Leipzig: F.C.W. Bogel, 1889. %

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8. Swanson NA. Classifications, definitions, and concepts in flap surgery. In: Baker SR

Swanson NA, eds. Local flaps in facial reconstruction, Mosby, 1995:63-74. 5

9. Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial |

skin defect reconstructions. Arch Otolaryngol Head Neck Surg 1998; 124:60-66.

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12. Cook TA, Brownlee RA. Rotation flaps. In: Baker SRSwanson NA, eds. Local Flaps in Facial Reconstruction, St. Louis, CV: Mosby, 1995:75-90.

13. Elliott RA, Jr. Rotation flaps of the nose. Plast Reconstr Surg 1969; 44:147-149.

14. Zitelli JA, Baker SR. Bilobe flaps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction, St. Louis, CV: Mosby, 1995:165-180.

15. McGregor JC, Soutar DS. A critical assessment of the bilobed flap. Br J Plast Surg 1981; 34:197-205.

16. Limberg AA. Modern trends in plastic surgery. Design of local flaps. Modern Trends Plast Surg 1966; 2:38-61.

17. Bray DA. Rhombic flaps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis, CV: Mosby, 1995:151-164.

18. Fee WEJ, Gunter JP, Carder HM. Rhomboid flap principles and common variations. Laryngoscope 1976; 86:1706-1711.

19. Koss N, Bullock JD. A mathematical analysis of the rhomboid flap. Surg Gynecol Obstet 1975; 141:439-442.

20. Roggendorf E. Rhombic and rhomboid Schwenklappen-plasty. In: Strauch B, Vasconez LO, eds. 2 ed. Grabb's Encyclopedia of Flaps, Philadelphia: Lippincott-Raven, 1998:359-364.

21. Rieger RA. A local flap for repair of the nasal tip. Plast Reconstr Surg 1967; 40:147-149.

22. Rieger RA. Lateral nasal (miter) skin flap. In: Strauch B, Vasconez LO, eds. 2 ed. Grabb's Encyclopedia of Flaps, Philadelphia: Lippincott-Raven, 1998:183-185.

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24. Spear SL, Kroll SS, Romm S. A new twist to the nasolabial flap for reconstruction of lateral alar defects. Plast Reconstr Surg 1987; 79:915-920.

25. Menick FJ. Reconstruction of the nose. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction, St. Louis, CV: Mosby, 1995:323-328.

26. Quatela VC, Sherris DA, Rounds MF. Esthetic refinements in forehead flap nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995; 121:1106-1113.

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28. Alford EL, Baker SR, Shumrick KA. Midforehead flaps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction, St. Louis, CV: Mosby, 1995:197-223.

29. Dolan R, Arena S. Clinical applications of the island-pedicled nasolabial musculocutaneous flap. Am J Rhinol 1995; 9:219-224.

30. Dolan R, Arena S. Reconstruction of the total columellar defect. Laryngoscope 1995; 105:1141-1143.

31. Juri J, Juri C. Cheek reconstruction with advancement-rotation flaps. Clin Plast Surg 1981; 8:223-226.

32. Licameli GR, Dolan R. Buccinator musculomucosal flap: applications in intraoral reconstruction. Arch Otolaryngol Head Neck Surg 1998; 124:69-72.

33. Gullane PJ, Arena S. Palatal island flap for reconstruction of oral defects. Arch Otolaryngol 1977; 103:598-599.

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