Transoral robotic reconstruction of a posterior palatal defect using an upper arm flap following polymorphous adenocarcinoma resection: a novel minimally invasive approach

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Abstract
Background: Surgical management of malignant tumors in the orofacial region frequently necessitates extensive resection, resulting in significant functional and aesthetic morbidity. In younger patients, these sequelae carry a substantial psychosocial burden, emphasizing the need for minimally invasive reconstructive strategies that preserve quality of life while maintaining oncological safety. Case presentation: A 36-year-old female patient presented with a small 1 × 1 cm swelling at the junction of the hard and soft palate on the left side. Incisional biopsy confirmed a malignant minor salivary gland tumor but did not permit definitive subtyping. The final diagnosis of a polymorphous adenocarcinoma (PAC), conventional subtype, was established only on the complete resection specimen. Following oncologically adequate resection, including partial hard palate and tuberosity removal, a 3 × 4 cm defect was reconstructed with a free upper arm flap. Supermicrovascular anastomoses to the superior labial and facial arteries (vessel diameter ~ 0.2 mm) were performed via a transoral approach using the Symani ® robotic surgical system with 20× motion scaling. Venous anastomoses to the facial vein were completed end-to-end and end-to-side via the same intraoral access. Selective lymph node sampling of the four radiologically prominent ipsilateral level II lymph nodes through a minimal cervical incision showed no metastases, both on frozen section and on final histopathology (0/4). Final histopathology demonstrated a 15 mm low-grade PAC resected in sano, without lymphovascular invasion, without unequivocal perineural infiltration and without bone invasion, classified as pT1 pN0 (0/4) cM0, R0. Postoperative course was uneventful; functional rehabilitation including speech and swallowing therapy is ongoing. Conclusions: Robotic-assisted supermicrosurgery using the Symani ® system enabled safe transoral free flap reconstruction of a posterior palatal defect with anastomoses at the sub 0.2 mm scale. This approach minimizes donor-site morbidity and demonstrates the feasibility of intraoral robotic supermicrosurgery as a novel reconstructive modality in head and neck oncology.
Funding Information
  • Universitätsklinikum Schleswig-Holstein - Campus Kiel

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