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Our Technique of “Tongue” Folding

Chiu, Tor F.R.C.S.(Glas.); Burd, Andrew F.R.C.S.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 426-427
doi: 10.1097/PRS.0b013e3181904e5b
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We were very interested to read the tips described by Davison et al. for maximizing flap inset during tongue reconstruction.1 Our flap of choice is the anterolateral thigh flap, and in our experience, the cosmetic and functional results have been good. Similar to Davision et al., we de-epithelialize an area of the flap, though we use it primarily to fold the essentially flat flap into a three-dimensional tongue.

  • Our practice is to harvest the flap from the contralateral thigh, as this makes a “two-team” approach much easier.
  • An elliptical flap is marked out to size, with the length accounting for the length of the tongue resected as well as the undersurface and anterior floor-of-mouth defect, if any. The width is the sum of the width of tongue resected, the height of the tongue, and the lateral floor-of-mouth defect.
  • Where possible, the perforators (identified preoperatively with a handheld Doppler probe) are positioned in the proximal third of the flap. The medial edge is raised first and the final position of the flap is adjusted according to the actual perforators; the final dimensions are tailored to the resected specimen.
  • The flap is partly inset into the defect from a posterior to anterior direction; when the medial side of the flap has been sutured close to the tip of the tongue, we de-epithelialize a corner (Fig. 1, above; sometimes this is excised depending on the bulk of the flap). When the edges of this corner are sutured together, the flap folds itself along the dotted lines, forming a three-dimensional tongue-like shape (Fig. 1, below).
Fig. 1.
Fig. 1.:
(Above) The de-epithelialized corner is indicated by the triangular area within the dotted lines. (Below) When the edges of this corner are sutured together, the flap folds itself along the dotted lines, forming a three-dimensional tongue-like shape.

Thus far, in our series of 25 cases we have not found any distal flap necrosis, regardless of whether the corner was de-epithelialized or resected; we believe that this reflects the good vascularity of the anterolateral thigh flap. We look forward to incorporating the hints offered by Davision et al. in future reconstructions.

Tor Chiu, F.R.C.S.(Glas.)

Andrew Burd, F.R.C.S.

Plastic, Reconstructive, and Aesthetic Surgery

Prince of Wales Hospital

Chinese University of Hong Kong

Shatin, Hong Kong


1. Davison S, Grant N, Schwarz K, Iorio M. Maximizing flap inset for tongue reconstruction. Plast Reconstr Surg. 2008;121:1982–1985.

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