Anterior-based Tongue Flap for the Closure of Posterior Palatal Defect: A Case Report

BACKGROUND

An unusual communication between the oral cavity and nasal cavity is considered to be a palatal fistula. A palatal fistula can occur as a result of any trauma, cyst, neoplasm, radiation therapy or infectious lesions, granulomas, and syphilis, even after surgery of cleft palate.¹

The affected patients usually complain of uncontrolled regurgitation via the nose, a variable amount of speech impairment because of velopharyngeal insufficiency, which impairs the articulatory abilities resulting in a hypernasal speech.^2,3

In 1901, Eiselberg first used pedicled tongue flaps for surgical management of intraoral defects. However, it was Guerrero-Santos and Altamirano, in 1966, who advocated the use of tongue tissue for managing hard palate deformities.

The vascular supply of the tongue is via the lingual artery with its four branches, namely, supra hyoid, dorsal lingual, deep lingual, and sublingual artery.

In addition to the extensive contralateral anastomotic network,⁴ clinical applications of tongue flap reside primarily with reconstruction surgeries of oral defects including that of the hard and soft palate, oroantral fistula closure, alveolar clefts, oral submucous fibrosis, and in certain lip reconstructions.⁵

CASE DESCRIPTION

A 21-year-old man reported to the Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar with a post-traumatic posterior palatal fistula having difficulty in swallowing and speech along with regurgitation of fluids through the nose due to an oroantral communication present distal to tooth 25. A CT facial bones revealed a posterior palatal defect measuring 8 mm × 12 mm × 4 mm. Anteriorly based tongue flap was chosen to be the plan of reconstructive procedure. The patient surgically prepared and general anesthesia was induced under nasotracheal intubation.

Peripheral edges of the fistula were injected with 2% lignocaine containing 1:20,0000 adrenaline. A circumferential incision was placed around the fistula. The nasal mucosal layer was carefully dissected and raised, and nasal layer was closed using tension-free resorbable sutures.

A U-shaped pedicle of anteriorly based tongue flap was dissected, raised, and rotated upwards, which was sutured to the revised edges of the palatal defect. The oroantral communication distal to the left second premolar was closed using a FAMM. The patient was put on feeding via Ryle’s tube after the first stage of surgery. The vascularity of the tongue flap once confirmed, the pedicle was separated from the donor site after a period of 3 weeks under general anesthesia, and the raw surface defect was sutured using 3-0 vicryl. The patient was discharged after confirming the vascularity of the flap and was put on a soft diet. Regular follow-up was done after every 1 week for 3 weeks and then after 1, 3 and 5th months postoperatively.

This procedure completely eradicated the chief complaints of the patient thus providing utmost satisfaction to the patient as well as the operating team (Figs 1 to 5).

DISCUSSION

Local flaps that can be used for the reconstruction of small- to moderate-sized palatal defects include the palatal island flap,⁶ buccinator myomucosal flap,⁷ buccal fat pad flap,⁸ and a multivariate option of tongue flap designs that can be based anteriorly, posteriorly, and laterally.^1,2 Intraoral defects having diameter larger than 1.5 cm are difficult to manage with local buccal or palatal flaps because they may lead to an inadequate closure as a result of an insufficient quantity of donor tissue.⁹

Hence, defects having diameters of 1.5–3.5 cm can be best treated with dorsal tongue flaps, considering their excellent vascular supply and abundant soft tissue for reconstruction.⁹

Tongue flaps are also used in the management of defects of the tonsillar area, tongue base, soft palate, buccal mucosa, and floor of the mouth.⁹

However, contraindications of its use include large pharyngeal defects that extend into the piriform sinus or defects that can heal by secondary intention or with a simple skin graft.⁹

The location and size of the defect remain the prime consideration while planning the extensions of the tongue flap. The diameter of the flap should be 20% greater than the defect to obtain a tension-free closure and a minimum thickness of 3 mm to incorporate viable submucous plexus.

Flaps of 10 mm thickness and length up to 2/3 of the dorsum of the tongue can be used if more bulk is required.¹⁰ Posteriorly based flaps are better suitable for defects of the soft palate, retromolar area, or posterior buccal mucosa. Whereas, anteriorly based flaps are suitable for defects of the hard palate, anterior buccal mucosa, floor of the mouth and lips.¹¹

The flap may appear to be unhealthy or dusky in color following surgery, but the absence of fistula in the early postoperative period warrants the success of the flap.¹² In cases of vascular flap congestion, systemic heparin can be used.⁹

Pin pricking the flap helps in venous outflow. Hyperbaric oxygen as an adjunctive methodology can also be employed, if required.⁹ The division of flap in this case was done after 3 weeks.

Postoperative complications include hematoma, dehiscence, lack of sensation, and taste perception, none of which were encountered in this particular case.

CLINICAL SIGNIFICANCE

Tongue flap, commonly termed “workhorse flap” in the repair of palatal defects is recommended provided that patient selection and surgical technique are meticulous.¹³

CONCLUSION

Tongue flaps are versatile flaps with only the disadvantage of a two-stage procedure.

ACKNOWLEDGMENTS

The mentors of the authors guided them through this case and helped in achieving rehabilitating results.

REFERENCES

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8. Abbas K, Behnam B, Mohammad M, et al. Effectiveness of buccal fat and closing residual mid palatal and posterior palatal fistulas in patient’s previously treated for clefts. J Oral Maxillofac Surg 2011;69:e416–e419. DOI: 10.1016/j.joms.2011.02.010.

9. Beech R, Reid J, Fung H, et al. Anteriorly based tongue flap for closure of a posterior palatal defect in a patient with exaggerated gag reflex. World J Med Surg Case Rep 2015; 4:43–50. https://www.npplweb.com/wjmscr/content/4/10.

10. Smith TS, Schaberg SJ, Collins JT. Repair of a palatal defect using a dorsal pedicle tongue flap. J Oral Maxillofac Surg 1982;40(10):670–673. DOI: 10.1016/0278-2391(82)90120-3.

11. Vasishta SM, Krishnan G, Rai YS, et al. The versatility of the tongue flap in the closure of palatal fistula. Craniomaxillofac Trauma Reconstr 2012;5(3):145–160. DOI: 10.1055/s-0032-1313352.

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13. Gupta N, Shetty S, Degala S. Tongue flap: a “workhorse flap” in repair of recurrent palatal fistulae. Oral Maxillofac Surg 2020;24(1):93–101. DOI: 10.1007/s10006-019-00823-9.