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Residual defects of the palatal region following ablative resection of tumors and Gunshot wounds (GSWs) of the maxillofacial region can be quite painstaking, daunting and challenging to reconstruct, due to the extent and composite nature of the tissue loss. A shortage of available donor areas and local flap options in the intraoral region, add to the difficulty. Further compounding the situation, are factors such as excessive fibrosis and scarring of the palatal tissues as a result of multiple previous surgeries in the region.
To evaluate the effectiveness of the Dorsal Pedicled Tongue Flap in the reconstruction of complex palatal defects resulting from maxillofacial GSWs and ablative tumor resections. To also device techniques to reduce the incidence of postoperative tongue flap detachment, thus improving its efficiency and reliability.
The palatal fistulas in all the patients were closed successfully, with no post-operative complications such as bleeding, hematoma formation, congestion, infection, partial or total flap necrosis or flap detachment. The tongue flap at the recipient site remained healthy with no recurrence of the fistula in any of the patients in the two years follow up period. There was a complete resolution of the problem of nasal regurgitation of orally ingested fluids and food particles. There was observed no deformity or articulation defect resulting from the flap harvested from the tongue dorsum, in any of the patients.
In GSWs and tumor ablative surgery, where composite tissue defects are involved, the tongue provides a reliable and efficient means of restoring lost tissue bulk as well as ensuring a permanent closure and sealing off of the oronasal fistulas. Its reliability can be further increased by avoiding a common complication, namely, flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also, maintaining the patient on Nasogastric feeding for the three weeks postoperative period, until the patient is taken up for surgical separation the pedicle. This helps to ensure a successful and predictable take of the flap at the donor site.
Oronasal communications are often encountered following trauma, ablative resection for tumors, gunshot injuries, and, most commonly, after previous attempts at closure of palatal and/or alveolar clefts.
Reconstruction of intraoral defects is of great importance to preserve the unique anatomy and functions of the oral cavity such as mastication, taste, swallowing, control and disposal of saliva, and phonation. Tissue defects in the oral region should be replaced with tissues, which have the best anatomical, histological, and functional similarity. Therefore, neighboring tissues seem to be the best donor site alternative. Intraoral local flaps, including palatal island flap, buccinator myomucosal flap, facial artery musculomucosal flap, and buccal fat pad flap, have been used in the past to reconstruct intraoral defects. The location and size of the intraoral defect would determine the reconstruction method of choice, such as primary closure, mucosal or skin grafts, local and regional flaps, and free tissue transfers.
Due to the inadequacy of tissue around anterior palatal fistulas, local mucoperiosteal flaps are of limited value in their closure. In such cases, tongue flaps have been found extremely useful in intraoral defect reconstruction.
In this case series, the value of the dorsal pedicled tongue flap in the successful closure of residual oronasal fistulas following gunshot wounds (GSWs) and tumor ablation has been presented.
Two adult male patients, of ages 25 and 27, respectively, reported with complaints of escape of air into the mouth while breathing, nasal regurgitation of food and fluids, halitosis, and a hypernasality in their voices. History revealed that they had sustained gunshot injuries to the face in separate incidents, 18 and 20 months ago, for which they had been operated [Figures [Figures11 and and2].2]. Healing of the wounds had been satisfactory following surgery, except for the persisting oronasal communications [Figures [Figures33 and and4],4], which was the cause for their presenting complaints. On examination, each of the patients had a through-and-through palatal defect of 1.5 and 2 cm, respectively. The surrounding palatal tissues appeared scarred and fibrosed [Figures [Figures3c,3c, ,dd and and4a4a].
The third patient, aged 24 years, had been operated for pleomorphic adenoma of the minor salivary glands in the anterior palate region [Figure [Figure5a5a--e].e]. Following the wide local excision that was carried out, he developed a persistent oronasal communication [Figure [Figure5f5f--hh].
Anterior nasal turbulence, namely, the Frication-like noise produced on forceful blowing of the nose, a perceptual attribute of anterior nasal defect/incompetence, was observed in all these cases. Both the mirror test and straw test were employed to perceptually evaluate the degree of nasal emission and hypernasality, which were then accordingly classified as moderate in all these three patients.
In all these three patients, the feasibility of local palatal mucoperiosteal flaps for reconstruction of the defect was ruled out due to the traumatized, scarred, fibrosed, and inadequate quality of the palatal tissues. An anteriorly based dorsal pedicled tongue flap seemed to be the most viable option, and the patients were explained as to the procedure and the postoperative limitations in speech and eating unit that they would experience, until a surgical detachment of the pedicle.
In all the patients, the first surgical session was carried out under general anesthesia. The palatal defect was closed with the tongue flap after freshening the margins of the recipient site [Figures [Figures4,4, ,66 and and7].7]. Following suturing of the dorsal tongue flap in place, three silk sutures were drawn through the tongue, one at its tip and one through each of its lateral borders and each suture was slung around the nearest upper tooth and tied, thus adapting the tongue to the palate and reducing the traction on the attachment of the dorsal tongue flap, thereby preventing its detachment and further stabilizing the flap in place [Figure [Figure6h6h--j].j]. All three patients were maintained on Ryle's tube nasogastric feeding for 21 days postoperatively. This was done to minimize movements of the tongue that would otherwise be unavoidable while eating/drinking and swallowing. Oral hygiene measures were undertaken using saline mouth rinses as well as gentle teeth cleaning using a finger with some toothpaste.
The patients were taken up under local anesthesia on the 22nd postoperative day for the second surgical session, namely, transection of the pedicle [Figures [Figures6i6i--l,l, ,8a8a--dd and and9a9a--d].d]. The palatal fistulas in all the patients healed successfully [Figures [Figures5e,5e, ,f,f, ,7e7e--hh and and9e9e--h],h], with no postoperative complications such as bleeding, hematoma formation, congestion, infection, partial or total flap necrosis, or flap detachment. The tongue flap at the recipient site remained healthy with no recurrence of the fistula in any of the patients in the 2-year follow-up period. Their phonation improved dramatically, and there was a complete resolution of the problem of nasal regurgitation of orally ingested fluids and food particles. There was observed no deformity or articulation defect resulting from the flap harvested from the tongue dorsum, in any of the patients [Figures [Figures8f,8f, ,9h9h and 10g].
The anteriorly based dorsal tongue flap was introduced by Guerrero-Santos and Altamirano in 1966 for the surgical closure of a large palatal fistula. In 1972, Assuncao described the rich submucous vascular plexus in the tongue and demonstrated that tongue flaps could be increased safely in any direction, even when only 3-mm thick. Eiselsberg was the first to use the tongue in the reconstruction of the oral cavity. Lexer reported the first posteriorly based pedicled tongue flap for coverage of a retromolar trigone defect occurring after oncological surgery. The tongue flap when compared to other reconstructive options, such as palatal and buccal flaps, mucoperiosteal island flaps, tubed pedicled flaps, nasolabial flaps, temporalis muscle flaps, and radial forearm free flaps, has the advantage of an abundant vascular structure with significantly decreased rates of fistula recurrence after surgery. The second advantage of dorsal tongue flaps is the ease of planning the flap in sufficient length, width, and depth needed for the location and dimension of the fistula. The tongue flap has the advantage of giving a good volume by adding muscular tissue.
Although the tongue flap is an extremely versatile and efficient means of closure of anterior as well as posterior, unilateral, and bilateral palatal defects and effectively functionally obliterates the oronasal communication, it has a few drawbacks. The main disadvantages of the tongue flap are the need for a second surgical procedure to detach the pedicle and the need for patient's compatibility with the procedure due to a functional loss-like difficulty in swallowing and speech due to the immobile tongue till depedicling.
Flap dehiscence and detachment during the early postoperative period is a troublesome complication due to tongue movements during normal activities such as speaking, swallowing, yawning, and coughing. The unbridled tongue exhibits vigorous and continuous movements that often tug at the pedicle and result in flap detachment. Another disadvantage is the peroral appearance of the repaired area and the tongue tissue appearing bulky, rough, and rather unnatural in the roof of the mouth. This article describes some of the methods which can be used to alleviate these problems. In this study, all the patients were kept on Ryles nasogastric tube feeding for 21 days until separation of the pedicle. This was done with the aim to help keep the tongue as immobile as possible, with the flap securely adapted at the defect site, to give it the best chance to take uninterrupted, and to reduce the chances of flap detachment in the postoperative period. All the patients were able to accommodate well with the procedure, and there was no issue at all with patient compliance. Further, all the patients were maintained on Ryle's nasogastric tube feeding for the 3-week postoperative period, until the patient is taken up for surgical separation of the pedicle, which helped to ensure a successful and predictable take of the flap at the donor site, by limiting the tongue movement due to chewing, swallowing, etc.
The tongue is an excellent donor site for oral soft-tissue reconstruction, especially for the closure of palatal fistulas due to its proximity to all intraoral structures and texture match, highly vascular and sturdy structure, bulkiness of the subjacent muscle, and less donor site morbidity. The few drawbacks that are encountered occasionally, such as flap detachment and dehiscence, can be prevented by ensuring the minimal mobility of the tongue in the early postoperative period. Its reliability can be further increased by avoiding a common complication, namely, tongue flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth, and also, by maintaining the patient on nasogastric feeding for the 3-week postoperative period, until the patient is taken up for surgical separation of the pedicle. This helps to ensure a successful and predictable take of the flap at the donor site.
In GSWs and tumor ablative surgery, where composite tissue defects are involved, the tongue provides a reliable and efficient means of restoring lost tissue bulk as well as ensuring a permanent closure and sealing off of the oronasal fistulas.
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
There are no conflicts of interest.