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Versatility and limitation of tongue flap in oral cavity reconstruction

Al Sayed, Fawzy T.

Egyptian Journal of Oral & Maxillofacial Surgery: January 2015 - Volume 6 - Issue 1 - p 9–16
doi: 10.1097/01.OMX.0000457453.05972.25
ORIGINAL ARTICLES
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Oral cavity reconstruction is challenging due to complex of anatomy and function. A tongue flap is frequently used for oral cavity reconstruction in median size defect (4–7 cm2). Thirty patients indicated for soft tissue reconstruction after tumor resection and residual palatal fistulae after primary palatal repair were included. Tongue flaps were used in 20 patients with successful outcome and low donor site morbidity. Ten patients with large-size oral defects were treated by temporalis muscle flaps, buccinator myomucosal flaps, and platysma myocutaneous flaps. Appropriate oral cavity reconstruction with successful outcome was achieved with improvement of the patient quality of life.

Department of Oral and Maxillofacial Surgery, Shebin El-Kom Teaching Hospital, Shebin El-Kom, Egypt

Correspondence to Fawzy T. Al Sayed, MS, PhD, FDSRCS (Ed), Department of Oral and Maxillofacial Surgery, Shebin El-Kom Teaching Hospital, 32111 Shebin El-Kom, Egypt Tel: +20 100 200 2029; fax: +20 482 221 883; e-mail: fawzy_tantawy1955@yahoo.com

Received October 12, 2014

Accepted November 12, 2014

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Introduction

Reconstruction of the oral cavity defects is challenging due to complex anatomy and function. Tongue flaps are frequently indicated for oral cavity reconstruction since the first surgery performed by Lexer and Chir 1 to reconstruct the retromolar area using posteriorly based lateral tongue flap. The tongue is a muscular and highly vascularized organ and its location at the center of the oral cavity makes it accessible for reconstruction of different anatomical area inside the mouth 2,3. The extensive anastomotic network of the tongue blood supply allows the use of different flap design according to the required reconstruction 2,4–6. Bracka 2 studied the blood supply of the tongue and reported that the viability of the tongue flap is not significantly affected even in case of ipsilateral lingual artery destruction during tumor resection. The problem of tongue flaps is the flap dehiscence due to early tongue movement. Additional fixation was postulated by many authors to avoid this mishap. Guerreno-Santos and Altamirano used the wire fixation to the tongue tip to upper lip during the time of flap healing 6. Steinhauser 7 used the maxilla mandibular fixation for this aim. Carreirão and Lessa 8 modified the surgery of the tongue flap by performing long flap pedicle to allow range of tongue movement without direct tension on the flap during the early stage of healing 7. As the tongue is one of the specialized and vital organs responsible for speech, taste sensation, mastication, and swallowing, the overuse of the tongue flaps in large oral cavity defects impairs the important tongue function and disturbs the patient desire of life. Several articles paid attention to the use of the tongue flap in medial size defect (4–7 cm) to preserve tongue shape and function 2,6,9,10. The capacity of the tongue flaps to reconstruct the larger defects is limited, and nearby regional flaps are usually indicated such as temporalis muscle flaps, buccinator myomucosal flaps, and platysma myocutaneous flaps 10–16. Recently, the use of free flaps is considered the ideal solution in case of large composite defects; in developing countries, the lack of facilities and surgical expertise keeps the traditional methods of reconstruction still alive 17,18.

This study aimed to revise the reliability and limitation of the tongue flap in oral cavity reconstruction.

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Patients and methods

A total of 30 patients (18 males and 12 females) with range of age 5–70 years and mean age 36.5 years were included. The cases were selected from the patients admitted to the Oral and Maxillofacial Surgery Department, Shebin El-Kom Teaching Hospital through the time from 2007 to 2013. Patients with advanced oral cancer and positive metastasis were excluded. Adequate investigation and required consultation were performed for each patient. Every patient and his relative were informed about the nature of surgery and postoperative follow-up, and medical consent was taken including the photographs. Different types of pathology were diagnosed and treated before reconstruction (Table 1). The choice of flap for intraoral reconstruction is dependent on the size and anatomical position of the defect; hence, the cases were selected randomly.

Table 1

Table 1

All patients were treated under general anesthesia with nasoendotracheal intubation.

Tongue flap was carried out with part of intrinsic muscle with thickness that ranged from 6 to 8 mm and enough long pedicle (Fig. 1). The tip of the tongue is not included in case of posteriorly based tongue flap and with slight angle to facilitate the linear closure of the donor site before transferring the flap to the recipient’s site. The site of the defect was repaired primarily according to the surrounding tissue permits. The flap was broad enough to be sutured without any tension. Nasogastric tube was performed at the first week postoperatively. Tongue flap used for cheek reconstruction usually crossing the teeth may endanger the flap during jaw mastication; hence, the crossed teeth must be extracted before. Continuous observation was performed to the flap with oral hygiene control for every patient.

Fig. 1

Fig. 1

After 3 weeks, palatal tongue flap was transected under general anesthesia through the following steps. As the tongue flap obstructs the way for intubation, the flap was transected during induction of anesthesia to facilitate intubation and then the flap was readjusted to both the palatal and tongue sides. Tongue flaps reconstructed at another place rather than the palate was transected and readjusted by the use of local anesthesia.

Posterior-based buccinator myomucosal flaps were used for gaining enough pedicle length. The opening of the parotid duct was relocated (Fig. 2). The superior-based buccinator myomucosal flap was sutured directly to the exposed palatal bone by soft 0.5 mm wire (Fig. 3).

Fig. 2

Fig. 2

Fig. 3

Fig. 3

The myocutaneous flap was harvested from the submandibular and submental areas including the thin sheath of platysma muscle crossing to the oral cavity through a submandibular tunnel. The tunneled area of the flap was de-epithelialized for gaining primary healing to the defected area (Fig. 4).

Fig. 4

Fig. 4

Temporalis muscle flap was harvested through preauricular approach with temporal incision extended above the temporal lines; the muscle was separated from the temporal bone and rotated under the zygomatic arch with careful protection to the deep temporal arteries. Flap then crossing the maxillary defect was repaired by the residual palatal tissues (Fig. 5). Follow-up extended to 6 months for evaluation of flap viability and oral function.

Fig. 5

Fig. 5

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Results

The postoperative course of the flap viability and function was uneventful in 96.6% of patients, whereas in one patient tongue flap dehiscence occurred and revision was performed 1 month later by another tongue flap from the contralateral side with good result. The hospital stay ranged from 8 to 14 days. All patients have adequate mouth opening and the tongue regained its anatomical size and shape with good mobility and functions.

Resection of the tumors and reconstruction were performed in one surgery in 21 patients, whereas in nine patients the reconstruction was performed after the first operation of tumor resection and primary palatal surgery (Figs 6 and 7).

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Tongue flaps were indicated in 20 patients for palatal, buccal, and labial soft tissue reconstruction. Anterior-based dorsal tongue flaps were indicated in eight patients, posterior-based dorsal tongue flaps in three patients, lateral border posterior-based tongue flaps in six patients, and lateral border anterior-based tongue flap in further two patients (Fig. 8).

Fig. 8

Fig. 8

Regional flaps from the nearby tissues were indicated in 10 patients with larger defect greater than 7 cm except in one patient who had median size buccal defect after tumor resection at the retromolar trigone but refused the use of tongue flap.

Buccinator myomucosal flaps were used in five patients, temporalis muscle flaps were applied in three patients, and platysma myocutaneous flaps in two cases (Table 2 and Figs 9 and 10).

Table 2

Table 2

Fig. 9

Fig. 9

Fig. 10

Fig. 10

The follow-up for every case extended to more than 6 months. Every patient regained normal oral function, but dental rehabilitation in some cases of massive bone loss was difficult to be achieved by traditional prosthesis, and patients adapted themselves to use the other nonaffected side.

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Discussion

Oral cavity defects after different kind of ablative surgery and after failure of cleft palate repair usually are associated with serious functional disorders in mastication, speech articulation, and with psychological disturbances. Early rehabilitation was instituted since long time using the artificial prosthesis without complete satisfaction 19. Surgery for intraoral reconstruction by tongue flap had been commenced since more than 100 years by Lexer and Chir 1. There has been surgical progress development of different kinds of flaps. Recently, free flaps are increasingly indicated for intraoral reconstruction after massive resection of both hard and soft tissues with successful outcome and in turn the patient’s quality of life is improved. However, the wide application of free flaps is still restricted in developing countries due to lack of facilities and experienced surgeons 4–9,17,20–25.

Tongue flaps are flexible for intraoral reconstruction with low tongue morbidity. The minor contour defect appears after flap resection is going to be improved in short time.

The side effect of tongue mobility at the early stage of healing of the flap especially at the palatal area was considered in this study using tongue flap with long pedicle to give a range of tongue movement without tension on the flap as well as additional supportive sling was performed by stitch between the proximal end of the flap and palatal tissue nearer to the defect. Use of nasogastric tube for feeding at the first week postoperatively precludes the tongue movement during swallowing; all of these precautions increase the chance of flap stability reflected on the good results of this study, which correlated with the results of Carreirão and Lessa 8, Guerreno-Santos and Altamirano 5, and Anuja et al. 6 in their studies on using tongue flaps in intraoral reconstruction.

Oronasal fistula is one of the common complications after cleft palate repair and postmaxillary tumor resection; the use of local palatal flap is usually difficult due to soft tissue restriction and scaring. The use of tongue flap in this study has been regarded as a convenient and effective mean for treating this problem 3–5,7,8,23,24.

Ganguli 24 used the tongue flaps for reconstruction of different intraoral defects in large series of 142 patients with good functional results. DeSanto 25 studied the effect of radiotherapy on tongue flap viability with conclusion of no significant change in comparison with nonirradiated tongue flaps.

The use of buccinator myomucosal flaps in intraoral reconstruction is usually performed more than tongue flaps. Different flap design is usually applied according to the site of defect. Posterior-based pedicle myomucosal flap was used in this study for intraoral reconstruction of large maxillary defect. The need for long pedicle usually faced by the mucosal part of the parotid duct indicates relocation of the parotid duct opening superiorly with good functional outcome of both parotid gland and flap. The feel of immobile cheek and obliteration of the buccal vestibule are common patient complaint. In case of bare palatal bone created after resection of large sessile palatal mass, the myomucosal flap could be sutured directly with bone edge around the defect with outcome of good healing and complete closure of the oroantral communication 13–15.

Temporalis muscle flap is one of the regional flaps used in different places at the maxillofacial area. The intraoral application for reconstruction is very important for reconstruction of large defects, but the flap needs extra care for protection of the vascularity during flap rotation inside the mouth and the unesthetic hollowing of the temporal area 10–12. The three cases treated in this study by temporalis muscle flap have successful outcome with reconstruction of the temporal dimpling by temporalis fascia, and this correlated with the study by Ahmed Djae et al.12.

Platysma myocutaneous flaps are essential in case of floor reconstruction and the problem of hair growing within the flap does not take a long time. The drooling of saliva through the tunneled area was treated successfully by de-epithelialization of the tunneled part of the flap for induction of primary healing 15,16,21.

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Conclusion

Oral cavity reconstruction is very important for improving the quality of life in cases of oral defects. The intraoral central position of the tongue takes the advantage of providing the oral cavity with vascularized mucosal flaps required for reconstruction of moderately size defects without impairment of tongue function. In case of larger defects, other options are available nearby the oral cavity for reconstruction. Nowadays, the broad indication of the free flap is still not available in every center. Hence, we should use our resources and experience to help our patients.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

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