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).
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).
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.
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.
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.
Conflicts of interest
There are no conflicts of interest.
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