|Year : 2013 | Volume
| Issue : 2 | Page : 215-218
Tongue flap revisited
Anuja Deshmukh1, Subbiah Kannan1, Purvi Thakkar1, Devendra Chaukar1, Prabha Yadav2, Anil D’Cruz1
1 Department of Head and Neck surgery (Surgical Oncology), Tata Memorial Hospital, Mumbai, India
2 Department of Plastic & Reconstructive Surgery, Tata Memorial Hospital, Mumbai, India
|Date of Web Publication||13-Jun-2013|
Department of Head & Neck Oncology (Surgical Oncology), Tata Memorial Hospital, Dr. Ernest Borgers Road, Parel, Mumbai
Source of Support: None, Conflict of Interest: None
Aim: To assess the usefulness of single-staged posteriorly based dorsal tongue flap in oral cavity reconstruction following ablative surgery, in terms of flap viability, functional outcome and donor site morbidity.
Materials and Methods: A prospective database of patients who were reconstructed with dorsal tongue flap between July 2006 and November 2010 was used.
Results: There were 27 patients who had tongue flap reconstruction in this period. Size of the defect following excision ranged from 3.5-5 cm in greatest dimension. Marginal mandibulectomy was done in thirteen patients and in twelve patients mucoperiosteal stripping was done. There was no partial or total flap loss in our series. Two patients had minor salivary leak which was managed conservatively. All the patients had adequate mouth opening, good swallowing and speech following surgery.
Conclusion: Dorsal tongue flap is a simple and reliable flap for intra oral reconstruction. It provides good functional results without much morbidity.
Keywords: Mouth neoplasms, oral surgery, surgical flaps
|How to cite this article:|
Deshmukh A, Kannan S, Thakkar P, Chaukar D, Yadav P, D’Cruz A. Tongue flap revisited. J Can Res Ther 2013;9:215-8
| > Introduction|| |
The treatment of the oral cavity malignancy is mostly surgical excision. Oral cavity defects following oncological surgery are complex. Appropriate reconstruction plays an important role in improving the quality of life of these patients. Nowadays these defects are being increasingly reconstructed with free flaps. In developing countries, every patient cannot be offered free flaps because of increased cost, lack of expertise, increased operating time, etc. Local flaps like tongue flap can be used in select group of patients like
Moderate size defects (3-5 cm),
Defects where bone is exposed (marginal mandibulectomy)
Defects close to retromolar trigone (RMT) (avoid post-operative trismus)
High risk patients (avoid prolonged surgery)
Thus local flaps are used in those defects which are neither so small too close primarily or spilt thickness skin graft (SSG) (contraction) nor too large to use free flap (over kill). Mandible in situ reconstruction with pectoralis major myocutaneous flap is difficult and over kill.
Tongue which is adjacent to the site of excision can be used as it's highly vascular, elastic and central in location. Tongue flap takes advantage of these properties of tongue but within narrow limits. The principle of tongue flap is equitable redistribution of mucosa from relative abundance on the tongue to an adjoining excisional defect without significantly hampering the functions of the tongue.
Posteriorly based dorsal tongue flap is a good option for certain selected cases. Also there is no significant morbidity at the donor site. It permits primary closure of the donor area without tension and it is a single staged procedure. It can be used safely in irradiated patients.
The aim of this paper is to present our clinical experience with single- staged posteriorly based dorsal tongue flaps. We also present the indications and types of tongue flap and clarify the technique of posteriorly based dorsal tongue flap.
| > Materials and Methods|| |
Twenty seven patients who underwent dorsal tongue flap between July 2006 and November 2010 were analyzed. Tongue flap was used in lesions close to RMT, lower alveolus, where bone was exposed but mandibular continuity was maintained.
The site and stage of the tumor and type of resection were recorded. The patients were followed up to assess the flap viability and functional (speech and swallowing) outcome.
Anatomic basis for dorsal longitudinal tongue flap:
Lingual artery which supplies the tongue runs above the greater horn of the hyoid bone, deep to hyoglossus and passes towards the tip. It divides into four branches, viz. suprahyoid artery, dorsal lingual artery, deep lingual artery and sublingual artery.  There is extensive anastomotic network with branches from the contralateral side at the tip and base. The dorsal longitudinal tongue flap is based on the branches of the dorsal lingual artery. 
The mucosa over the ventral aspect of the tongue is smooth whereas on the dorsal surface the mucosa becomes papillary and is closely adherent to the underlying connective tissue called corium. The corium contains numerous penetrating vessels and nerves. The corium is closely adherent to the intrinsic musculature of the tongue, so a layer of intrinsic muscle is included in the flap.
Approximately 6-7 mm thick dorsal tongue flap is raised from one half of the tongue [Figure 1]. A layer of intrinsic muscle is included in the flap in order to prevent injury to its vascularity [Figure 2]. A slightly angled outline for the tip of the flap facilitates a smooth linear closure of the donor wound [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Posteriorly the flap can be extended till circumvallate papillae and medially up to the midline.
The remaining tongue narrows after flap elevation, but it does not shorten the body of the tongue [Figure 3] and [Figure 4]. The flap can be used for covering defects of retromolar trigone (RMT), suitable buccal mucosa and mandible (following marginal mandibulectomy) [Figure 4] and [Figure 5].
The dorsal tongue flap requires an edentulous space to admit the flap from the lingual to the buccal space without danger of compression between the jaws. This can be achieved by extraction of appropriate teeth. Second stage for division of the tongue flap pedicle is not required. The area of mucosa buried below the flap, is incised and opened up and the flap is inserted [Figure 4].
| > Results|| |
There were twenty three males and four females with age ranging from 31 to 78 years (median age 51 years).
Buccal mucosa was the most common site of primary cancer (22 patients), four patients had lesion in the lower gingivo- buccal sulcus and one patient had a soft palate lesion.
Size of the defect following excision ranged from 3.5-5 cm in greatest dimension. Fifteen patients had T1 lesion, ten patients had T2 lesion and two patients had verrucous hyperplasia [Table 1].
Marginal mandibulectomy was done in thirteen patients, in twelve patients mucoperiosteal stripping was done. Wide excision was done in two patients where the lesion was close to RMT.
In sixteen patients the tumor was approached by a midline lip spilt incision, in nine patients the angle spilt approach was used. Two tumors were excised intraorally.
The most common histopathology was moderately differentiated squamous cell carcinoma which was reported in fourteen patients, followed by poorly differentiated carcinoma in four patients, verrucous carcinoma in three and well differentiated carcinoma in three patients. In our series we had two verrucous hyperplasia and one mucoepidermoid carcinoma.
The flap elevation time was less than twenty minutes in all cases. All the flaps were done by resident doctors under supervision.
There was no partial or total flap loss in our series. Two patients had minor salivary leak which was managed conservatively.
All the patients had adequate mouth opening, good mobility of tongue, good swallowing and speech following surgery.[Figure 5], [Figure 6] Swallowing and speech results are subjectively assessed by patient, speech pathologist and clinician.
| > Discussion|| |
Oral cavity defects following oncological surgery are complex. Nowadays these defects are being increasingly reconstructed with free flaps. In developing countries, every patient cannot be offered free flaps because of increased cost, lack of expertise, increased operating time and anesthetic constraints in old age. Moreover free flaps are not without donor site morbidity. Distant pedicled flaps may be too bulky for repair of small intraoral defects with intact mandibular continuity. Local flaps like tongue flap can be used in moderate size defects (which cannot be closed primarily), defects where bone is exposed (SSG cannot be used) or when post-operative trismus needs to be avoided.
SSG for moderate sized lesions over the RMT area can cause trismus and also the take of SSG over the exposed bone is poor. Vascularized flaps (tongue flap and free flaps) can overcome these problems. On the other hand free flaps need an expert in microvascular anastomosis. There is need for anastomosis, so operating time is increased. Vigilant monitoring of flaps is needed in the initial postoperative period.
The advantage of tongue flap is that it is easy and quick to harvest. In our series it took around 20 minutes to harvest the flap and all flaps were harvested by resident doctors.
Lexer described the lateral tongue flap for retromolar trigone and tonsil area in 1909.  But it was Klopp and Schurter popularized posterolateral tongue flap for soft palate and tonsillar lesions.  Guerrero -Santos , Bakamjian , and McGregor  described the tongue transfer flap for palatal and lip defects. Hiranandani  described tongue flap for pharyngeal defects. Som and Nussbaum  described lateral tongue flap for floor of mouth after marginal mandibulectomy. Jackson , described dorsal tongue flap for palatal defects. Sisson and Lore  described sliding tongue flap for hypopharyngeal defects and Calamel  described anteriorly based dorsal tongue flap for floor of mouth defects.
There are various types of tongue flap dorsal anteriorly or posteriorly based, dorsal transverse flap, flaps from tongue tip dorsal and ventrally orientated, perimeter flaps, ventral tongue flaps. Anteriorly based dorsal tongue flap is used for the closure of palatal defects. Tongue flaps from tip are used for lip reconstruction, and floor mouth reconstruction. Posteriorly based dorsal tongue flap is used following marginal mandibulectomy, soft palate, tonsil or buccal mucosa wide excision. It's a single staged procedure.
The main concern with tongue flap is alteration of speech and swallowing. Some surgeons fear that removal of the tongue tissue may interfere with articulation; this fear is unwarranted based on our observation and many other. ,,,,,, Speech depends on the mobility of the tongue. Unlike lateral tongue flap, floor of the mouth is not included in dorsal tongue flap, hence tethering or fixation of the tongue does not occur, therefore speech is not affected. Swallowing mainly depends on the bulk of the posterior third of the tongue. Dorsal tongue flap does not cross the circumvallate papillae, so the swallowing is not affected.
| > Conclusion|| |
Single- staged posteriorly based dorsal tongue flap is a simple and reliable flap for intra oral reconstruction of moderate size defects. It can be used in select group of patients with trismus, high risk for prolonged surgery and with bone exposed. It provides good functional results without much morbidity.
| > References|| |
|1.||Bracka E. The blood supply of the dorsal tongue flaps. Br J Plast Surg 1981;34:379-84. |
|2.||Komisar A. The applications of tongue flaps in head and neck surgery. Bull N Y Acad Med 1986;62:847-53. |
|3.||Klopp CT, Schurter M. The surgical treatment of cancer of the soft palate and tonsil. Cancer 1956;9:1239-43. |
|4.||Guerrero-Santos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the palate. Plast Reconstr Surg 1966;38:123-8. |
|5.||Carreirão S, Lessa S, Tongue flaps and the closing of large fistulas of the hard palate. Ann Plast Surg 1980;4:182-90. |
|6.||Bakamjian V. Use of tongue flaps in lower-lip reconstruction. Br J Plast Surg 1964;17:76. |
|7.||Bakamjian VY. Anteriorly and Posteriorly Based Pedicule Flaps from Dorsum of the Tongue. In: Conley J, Dickenson G, editors. Plastic and Reconstructive Surgery of the Face and Neck, Stuttgart: Thieme; 1972. p. 158. |
|8.||McGregor IA. The tongue flap in lip surgery. Br J Plast Surg 1966;19:253-63. |
|9.||Hiranandani LH. Tongue as pedicle flap for reconstruction of the pharynx in one-stage laryngopharyngectomy. Rev Laryngol Otol Rhinol (Bord) 1967;88:111-25. |
|10.||Som ML, Nussbaum M. Marginal resection of the mandible with reconstruction by tongue flap for carcinoma of the floor of the mouth. Am J Surg 1971;121:679-83. |
|11.||Jackson IT. Use of tongue flaps to resurface lip defects and close palatal fistulae in children. Plast Reconstr Surg 1972;49:537-41. |
|12.||Jackson IT. Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. Br J Plast Surg 1972;25:93-105. |
|13.||Lore JM. Tongue flap and dermal graft for reconstruction of entire hypopharynx, portion of oropharynx, and portion of cervical esophagus. In: Lore JM, editor. An Atlas of Head and Neck Surgery, Philadelphia: Saunders; 1973. p. 810. |
|14.||Calamel PM. The median transit tongue flap. Plast Reconstr Surg 1973;51:315-8. |
|15.||Calcaterra TC. Tongue flap reconstruction of the hypopharynx. Arch Otolaryngol 1983;109:750-2. |
|16.||Sessions DG, Dedo DD, Ogura JH. Tongue flap reconstruction in cancer of the oral cavity. Arch Otolaryngol 1975;101:166-9. |
|17.||Steinhauser EW. Experience with dorsal tongue flaps for closure of defects of the hard palate. J Oral Maxillofac Surg 1982;40:787-9. |
|18.||Guerrerosantos J. Intraoral reconstruction tongue musculomucosal flaps. In: Strauch B, Vasconez L, Hall-Findlay E, Lee BT, editors.. Grabb's Encyclopedia of Flaps. 3 rd ed. Philadelphia: Wolters Kluwer/Lippincott; 2008. p. 530-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]