Single-Stage Peninsular-Shaped Lateral Tongue Flap for Personalized Reconstruction of Various Small- to Moderate-Sized Intraoral Defects: A Retrospective Case Series with Tongue Function Evaluation Using the Functional Intraoral Glasgow Scale.

Herein, we present our experience using a single-stage peninsular-shaped lateral tongue flap (pLTF) to cover various intraoral defects and confirm the versatile utility and effective application of pLTF in intraoral defect reconstruction. This study included eight cases (six males and two females; average age 60.3 ± 16.9 years) of intraoral defect reconstruction performed by a single surgeon between August 2020 and May 2023 using the single-stage pLTF technique. Electronic medical records and photographs of the patients were collected and analyzed. The functional intraoral Glasgow scale (FIGS) was used to evaluate preoperative and postoperative tongue function. Defect sizes ranged from 3 cm × 3 cm to 4 cm × 6 cm. Notably, all defects were successfully covered with pLTFs, and the flap sizes ranged between 3 cm × 4.5 cm and 4.5 cm × 7.5 cm. The flaps completely survived without any postoperative complications. At follow-up (average, 9.87 ± 2.74 months), no patient had tumor recurrence or significant tongue functional deficits. The mean preoperative and postoperative FIGS were 14.75 ± 0.46 and 14.00 ± 0.92, respectively (p = 0.059). Thus, the single-stage pLTF technique is a good reconstructive modality for various small to moderate intraoral defect coverage in selected cases for personalized intraoral reconstruction.

The use of surgical template for palatal fistula repair in cleft palate using tongue flap: 3 case report.

INTRODUCTION AND IMPORTANCE: The occurrence of a palatal fistula after surgical correction in a cleft palate patient is the most common complication in cleft palate surgery. This condition might be due to poor tissue quality and vascularity, an error in the surgical technique, the size of the defect, the age of the patient, and infection. CASE PRESENTATION: Three patients with fistula in the anterior and mid-palate regions asked for correction. In past history, all cases had received multiple surgical corrections, and the result showed with recurrent fistula. DISCUSSION: Surgical interventions for correction of palatal fistula might be difficult as the surrounding tissue has lost its quality, especially in secondary surgery or after multiple surgical interventions. Flap taken from the tongue can be chosen as an alternative source to close the fistula based on the consideration that the tongue has a favourable position, and located as the nearest tissue directly opposite to the palatal region, and has good vascularity. The aim of this report is to show the advantages of the use a surgical template made from alumina foil to measure the size and shape of the flap in accordance with the form and size of existed fistula. The surgical template was used as a guidance during drawn the design of the flap on the surface of the tongue. CONCLUSION: The use of surgical templates was very useful as guidance during the marking procedure on the surface of the tongue for designing an individual tongue flap form.

Reconstruction of persistent oronasal communication using an anteriorly based tongue flap following failed cleft palate repair-Report of two cases.

The tongue flap is a suitable alternative to local mucoperiosteal flaps in closure of wide, persistent oronasal communications, surrounded by scarred and fibrotic tissue as a result of previously attempted palatoplasty. Herein, we report two cases with large recurrent oronasal communication closed using the anteriorly based dorsal tongue flap.

Primary Closure With Posteriorly Based Lateral Tongue Flap Reconstruction After Transoral Videolaryngoscopic Surgery for Tonsil Cancer.

INTRODUCTION: Transoral surgery for head and neck cancer provides excellent oncologic outcomes while preserving speech and swallowing function. When neck dissection and resection of oropharynx are performed concomitantly, there is a risk of creating a communication defect or developing a pharyngocutaneous fistula. To prevent pharyngocutaneous fistula, we performed the reconstruction using a posteriorly based lateral tongue flap for communication defect. PATIENT: A 72-year-old male with oropharyngeal cancer (tonsil cancer) T2N1M0 underwent concomitant transoral videolaryngoscopic surgery and neck dissection. The lateral wall of the oropharynx was resected with the pharynx constrictor muscle and parapharyngeal fat due to infiltration of the parapharyngeal space by the tonsil cancer. The posteriorly based lateral tongue flap was used to close the perforation. There was no leakage to the neck postoperatively. The patient had no problem with phonation or oral intake and remained free of disease at 12 months after treatment. CONCLUSION: For a small defect confined to the oropharyngeal lateral wall, the posteriorly based lateral tongue flap should be considered as a useful option for reconstruction of the oropharynx without impairment of posterior function.

Use of Indocyanine Green Fluorescent Imaging in the Assessment of a Tongue Flap After Lateral Hemiglossectomy.

Indocyanine green (ICG) angiography is a real-time imaging modality that can be used to assess intraoperative tissue perfusion. ICG dye has proven to be feasible, safe, and cost-effective, especially for muscle flaps during complex reconstructions. To our knowledge, we discuss the first use of ICG angiography for the real-time assessment of a tongue flap following left lateral hemiglossectomy. ICG angiography showed excellent perfusion of the tongue and tongue flap, which subsequently led to an uncomplicated postoperative recovery.

Closure of Oronasal Fistulae Post Palatoraphy with Tongue Flap in Bilateral Complete Cleft Lip Palate Patient: A Case Report

ABSTRACT@#Oronasal fistulae are common complication following palatoraphy. There are several surgical procedures to repair oronasal fistulae. However, conventional oronasal fistulae closure technique is not always possible, especially when the surrounding tissue is replaced by fibrotic tissue due to previous palatoraphy. Tissue defects in oronasal fistulae should be replaced with tissues providing good vascularisation such as pedicle tongue flap. A case of pedicle tongue flap used to close oronasal fistulae was reported. Eleven-year-old girl, presented with oronasal fistulae and bilateral alveolar cleft after previous palatoraphy. The oronasal fistulae were closed with pedicled tongue flap. The healing was uneventful, and the division of the pedicle tongue flap was done three weeks later and closed primarily. There was no dehiscence of the wound and masticatory functions were recorded. Vascularised flap such as pedicle tongue flap is a preferred technique to close oronasal fistulae after palatoraphy.

Reconstruction of an upper lip and intraoral defect following resection of an upper lip melanoma using a lower lip musculomucosal flap combined with a tongue flap.

Restoring the cosmetic and functional aspects of the lip after tumor resection is challenging. We report a case of reconstruction for a defect due to resection of a melanoma using a lower lip musculomucosal flap combined with a tongue flap. A 20-year-old man was referred to our hospital and diagnosed with malignant melanoma with metastatic right submaxillary lymph nodes. We excised the tumor with neck dissection. We excised not only the right upper lip mucosa but also the gum, including some orbicularis oris muscle and alveolar bone from the right canine tooth to the left central incisor tooth. The defect was simultaneously reconstructed using both, a lower lip musculomucosal flap and a tongue flap. Revisional operation to remove contraction of a postoperative scar and the right vermillion border collection was performed at 3 months after the initial operation. There had been no functional and cosmetic trouble of the upper lip.

The tongue flap for large palatal fistulas, a success or a failure? Our 15-year experience.

Large palatal fistulas after cleft palate surgery are difficult to treat using local mucoperiosteal flaps alone, particularly if multiple attempts to close the fistulas have resulted in tissue scarring. In this study, we present our 15-year surgical experience with tongue flaps for large palatal fistulas. A total of 34 patients who underwent tongue flap surgery at our institution between January 2000 and January 2015 were retrospectively analyzed. An anteriorly-based dorsal tongue flap was used for the treatment of anteriorly localized large palatal fistulas in all patients. Data including demographic characteristics of the patients, previous surgeries, localization of the fistula, time between the first and second surgery, and complications were recorded. Factors affecting the surgical success were evaluated. Of the patients, 21 were males and 13 were females with a mean age of 11.7 ± 6.9 (range: 4 to 29) years. Detachment of the tongue flap was observed in nine patients after surgery. Seven of the patients with detachment were male aged ≤6 years (p < 0.05). Resuturing the flap back to the defect did not significantly affect the results. Our study results suggest that proper patient selection and attentive and rigorous surgical technique have a critical importance in the tongue flap repair and tongue flap is not recommended for patients who are under seven years of age.

Tongue flap: a "workhorse flap" in repair of recurrent palatal fistulae.

AIM AND OBJECTIVE: A prospective study done to evaluate the efficacy of tongue flaps in secondary palatal defects, in terms of functionality, esthetics, and donor site morbidity, and to clarify the technique of elevating and insetting of tongue flap. MATERIALS AND METHOD: Twenty patients having recurrent secondary palatal fistula, post cleft treatment were treated with anteriorly and posteriorly based dorsal tongue flaps. Patients were evaluated for outcome in terms of flap uptake and effectiveness, correction of oronasal regurgitation, speech and articulation, donor site morbidity, and esthetics. RESULTS: Twenty patients in age range of 11-24 years, with secondary palatal fistulae, were treated with anteriorly/posteriorly based tongue flap. There were two recurrences as the flap got detached in one patient and necrosis of flap in another. In other patients, healing was uneventful. The flap showed good success rate in terms of uptake and correction of oronasal regurgitation, with imperceptible donor site morbidity. With speech therapy assistance and periodic evaluation by a therapist, significant improvement in speech and articulation was noted over time in all successfully healed patients. CONCLUSION: Use of tongue flap for repair of palatal fistulae is a successful technique as it provides appreciable quality and quantity of well-vascularized tissue for fistula closure with negligible functional and esthetic morbidity associated with donor site. As per our study, it is a reliable technique for palatal fistula closure. It even provides good speech improvement over time.

Use of an anteriorly based ventral tongue flap to reconstruct the lower vermilion following early-stage cancer ablation.

BACKGROUND: Reconstruction of lower vermilion defects is surgically challenging. AIMS: This study evaluated whether lower vermilion defects can be repaired using tongue flaps, and the reconstructive outcomes. MATERIALS AND METHODS: We evaluated 11 patients with early-stage lower vermilion cancers who underwent lower vermilion reconstruction using anteriorly based ventral tongue flaps following cancer ablation. We treated eight males and three females aged 54-67 years (median, 59.8 years). The defect/tongue flap dimensions ranged from 1.8 × 3.5 to 2.0 × 4.5 cm (median, 1.87 × 3.81 cm). RESULTS: No major complication developed in any patient. The postoperative esthetic results, orbicularis oris functions, and speech functions were excellent in six, eight, and nine patients, and satisfactory in five, three, and two, respectively. The patients were followed up for 13-36 months (median, 21.7 months); two local recurrences developed, and these patients underwent salvage surgeries. CONCLUSIONS: An anteriorly based ventral tongue flap is a safe and feasible option for reconstruction of lower vermilion defects.

Persistent symptomatic anterior oronasal fistulae in patients with Veau type III and IV clefts: A therapeutic protocol and outcomes.

BACKGROUND: The anterior oronasal fistulae neighboring the alveolar cleft could persist or reappear after the alveolar reconstruction with cancellous bone grafting. The persistent symptomatic anterior oronasal fistulae need to be repaired, but surgery remains a challenge in cleft care. Surprisingly, this issue has rarely been reported in the literature. The purpose of this long-term study was to report a single surgeon experience with a therapeutic protocol for persistent symptomatic anterior oronasal fistula repair. METHODS: This is a retrospective study of consecutive patients with Veau type III and IV clefts and persistent symptomatic anterior oronasal fistulae managed according to a therapeutic protocol from 1997 to 2018. Depending on fistula size, patients were treated with local flaps associated with an interpositional graft or two-stage tongue flaps (small/medium or large fistulae, respectively). The surgical outcomes were classified as "good" (complete fistula closure with no symptoms), "fair" (asymptomatic narrow fistula remained), or "poor" (failure with persistent symptoms). RESULTS: Forty-four patients with persistent symptomatic anterior oronasal fistulae were reconstructed with local flaps associated with interpositional fascia or dermal fat grafting (52.3%) or two-stage tongue flaps (47.7%). Most of patients (93.2%) presented "good" outcomes, ranging from 87% to 100% (local and tongue flaps, respectively). Three (6.8%) patients presented symptomatic residual fistula ("poor" outcomes). CONCLUSIONS: For the repair of persistent symptomatic anterior oronasal fistulae, this therapeutic protocol provided satisfactory outcome with low fistula recurrence rate.

Airway management in pediatric tongue flap division for oronasal fistula closure: A case report.

Oronasal fistulae (ONF) could remain after surgery in some patients with cleft palate. ONF ultimately requires intraoral surgery, which may lead to perioperative airway obstruction. Tongue flap surgery is a technique used to repair ONF. During the second surgery for performing tongue flap division, the flap transplanted from the tongue dorsum to the palate of the patient acts as an obstacle to airway management, which poses a great challenge for anesthesiologists. In particular, anesthesiologists may face difficulty in airway evaluation and patient cooperation during general anesthesia for tongue flap division surgery in pediatric patients. The authors report a case of airway management using a flexible fiberoptic bronchoscope during general anesthesia for tongue flap division surgery in a 6-year-old child.

Techniques to Improve Reliability and Predictability of the Dorsal Pedicled Tongue Flap in Closure of Palatal Defects and Oronasal Fistulae.

INTRODUCTION: Despite the improvement in surgical techniques in cleft palate surgery, oronasal fistulas continue to remain a challenge, usually the result of residual palatal and alveolar clefts and post-palatoplasty defects. The tongue flap is an extremely versatile, sturdy, reliable and efficient means of closure of anterior as well as posterior, unilateral and bilateral palatal defects, effectively functionally obliterating the oronasal communication, owing much of its success to its highly vascular structure, good mobility, texture match, central location and low donor site morbidity. However, it has a few drawbacks. Flap dehiscence and detachment during the early postoperative period is a troublesome complication owing to tongue movements during normal activities such as speaking, swallowing, yawning and coughing. AIM: This article describes some of the methods which can be used to effectively alleviate these shortcomings. METHODS: A protocol of immobilizing the tongue by tethering it to the maxillary teeth for the 3-week postoperative period, and also maintaining the patient on nasogastric feeding, until the patient is taken up for surgical separation the pedicle, was employed in all patients in this case series. RESULTS: There was a successful and predictable take of the tongue flap at the donor site, namely the palatal/oronasal fistula with its successful closure, in all the patients. CONCLUSION: Treatment of the oronasal fistula using a two-layer closure using the nasal mucoperiosteum together with an anteriorly based dorsal tongue flap is an easy and efficient method, whose 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 maintaining the patient on nasogastric feeding for the 3-week postoperative period.

Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair.

BACKGROUND: Recurrent palatal fistula is a common complication of cleft palate repair. The main causes are poor surgical technique or vascular accidents and infection. Local flaps are not adequate for larger and recurrent fistula. The aim of this study is to analyze the utility of tongue flap in recurrent and large palatal fistula repair. MATERIALS AND METHODS: From January 2008 to July 2016, 18 patients with recurrent palatal fistula were included in the study. All the patients had undergone repair of cleft palate and fistula previously. Tongue flap repair of the recurrent palatal fistula was performed in all 18 patients. The flaps were divided after 3 weeks and final inset was done. Flap viability, fistula closure, residual tongue function, esthetics, and speech impediment were assessed. RESULTS: In all the patients, fistula could be closed primarily by tongue flap. None of the patients developed flap necrosis while flap dehiscence and bleeding were observed in one patient each. No functional deformity of the tongue and donor-site morbidity was seen. Speech was improved in 80% cases. CONCLUSION: The central position, mobility, excellent vascularity, and versatility of tongue flap make particularly suitable choice for the repair of large fistula in palates scarred by previous surgery. It is very well tolerated by children. We, therefore, recommend tongue flap for large and recurrent palatal fistula in children.

A retrospective analysis of incidence and management of palatal fistula.

BACKGROUND: Cleft palate repair may be compromised by a number of complications, most commonly the development of a fistula. Fistulas may cause hypernasal speech, articulation problems and food or liquid regurgitation from the nose. OBJECTIVE: The study determines the incidence and management of cleft palatal fistulas in a series of primary cleft palate repair surgeries. It is a retrospective analysis of total 185 palatal fistula cases operated at our hospital from the year 2004 to 2016. SUBJECTS AND METHODS: Of 185 palatal fistulas, 132 cases had been operated at our institute for primary palatoplasty, and the rest 53 were the outside-operated cases. The patients with bilateral as well as unilateral cleft lip and palate were included. Isolated cleft palate patients were also included in the study. Palatal fistulas were subdivided into three types depending on their size. Anterior palatal fistulas were mostly treated by using tongue flap (65.57%), followed by local flaps (34.43%). Middle and posterior palatal fistulas were mostly treated by von Langenbeck Palatoplasty. One patient (>5 mm fistula) was treated using free radial forearm flap. RESULTS: Anterior palatal fistulas (65.57%) were most commonly reported, followed by middle (24.86%) and posterior (9.18%). Most commonly, the size of the fistulas ranged from 2 mm to 5 mm. The complication rate was reported to be 3.75% in case of tongue flap and 11.9% complications were reported in case of local flaps. CONCLUSION: Tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulas compared to local flaps.

Airway management in pediatric tongue flap division for oronasal fistula closure: A case report

Oronasal fistulae (ONF) could remain after surgery in some patients with cleft palate. ONF ultimately requires intraoral surgery, which may lead to perioperative airway obstruction. Tongue flap surgery is a technique used to repair ONF. During the second surgery for performing tongue flap division, the flap transplanted from the tongue dorsum to the palate of the patient acts as an obstacle to airway management, which poses a great challenge for anesthesiologists. In particular, anesthesiologists may face difficulty in airway evaluation and patient cooperation during general anesthesia for tongue flap division surgery in pediatric patients. The authors report a case of airway management using a flexible fiberoptic bronchoscope during general anesthesia for tongue flap division surgery in a 6-year-old child.

A Study on Dorsal Pedicled Tongue Flap Closure of Palatal Fistulae and Oronasal Communications.

INTRODUCTION: 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. OBJECTIVE: 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. RESULTS: 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. CONCLUSION: 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.

Tratamiento de fistula palatina anterior mediante colgajo de lengua / Treatment of anterior palatal fistula through tongue flap

La fístula palatina anterior es la comunicación anormal entre la cavidad oral y la nariz que se presenta después del cierre quirúrgico de la fisura palatina, ésta ocurre con más frecuencia en defectos de paladar duro. El colgajo de lengua está indicado para la reconstrucción de grandes fístulas palatinas y con excesivas cicatrices palatinas luego de varios procedimientos insatisfactorios. El colgajo ofrece varias ventajas ya que presenta abundante tejido, excelente irrigación y es de fácil rotación. El resultado fue satisfactorio.

The anterior palatal fistula is the abnormal communication between the oral cavity and nose that occurs after surgical closure of cleft palate, this occurs more frequently in hard palate defects. Tongue flap is indicated for the reconstruction of large fistulas and excessive palatal scars after several unsatisfactory procedures. The flap offers several advantages since it presents abundant tissue, excellent irrigation and easy rotation. The result was satisfactory.

Remifentanil for sedation and analgesia during awake division of tongue flap in children: a report of two cases.

BACKGROUND: The tongue flap is an accepted treatment method for cleft palate repair. Orotracheal or nasotracheal intubation using a fiberoptic scope is preferred for the division of the tongue flap. We report two cases of tongue flap division in which the patients received adequate sedation and analgesia without tracheal intubation. CASE PRESENTATION: Twelve- and 13-year-old male patients were treated at our hospital for tongue flap division, performed as part of a cleft palate repair. We planned to divide the tongue flap under sedation with remifentanil (1 µg/kg/min continuous infusion) and local anesthesia, followed by induction of general anesthesia, and orotracheal intubation after the tongue flap was divided. During the procedure, patients were breathing spontaneously and were cooperative. Patients were able to follow the surgeons' verbal cues to thrust out the tongue during the procedure, so that the surgeons could easily insert the sutures. CONCLUSIONS: During the division of the tongue flap in two children, excellent sedative and analgesic effects were achieved using continuous remifentanil infusion.