British Journal of Oral Surgery (1983) 21, l-10 @ 1983. The British Association of Oral Surgeons

THE VERSATILITY OF THE LATERAL TONGUE FLAP IN THE RECONSTRUCTION OF DEFECTS OF THE ORAL CAVITY

E. D. VAUGHAN,F.R.C.S., F.D.s.R.c.s.'*, and A. E. BROWN, M.B., B.S., F.D.s.R.c.s., F.D.s.R.c.P.s.~

‘Department of Oral and Maxilla-facial Surgery, King’s College Hospital, Denmark Hill, London, S.E.5, 2Department of Oral and Maxilla-facial Surgery, Queen

Victoria Hospital, East Grinstead, Sussex

Summary. The full thickness, posteriorly based, lateral tongue flap is described and the excellence of the blood supply is emphasised. The surgical technique is discussed and the application of the flap in the reconstruction of defects of the palate, cheek and floor of the mouth is illustrated. The versatility of the method is stressed, together with advantages over regional skin flaps when used for the same purpose.

Intruductiuu

A variety of tongue flaps have been described in the literature. (Conley et al., 1957 ; Bakamjian, 1964 ; Guerrero-Santos & Altamirano, 1966 ; McGregor, 1966 ; Chambers et al., 1969; Jackson, 1972; De Santo, 1974; Converse, 1977; Carlesso et al., 1980). They all rely on the excellent blood supply to this organ which is derived from the lingual artery. Four named branches are recognised (Fig. 1) :

(1) The suprahyoid, which runs superior to the hyoid bone and supplies the muscles attached to it.

(2) The dorsalis linguae, which supplies the posterior third of the tongue. (3) The sublingual, one of the two terminal branches, which emerges deep to

hyoglossus to supply the floor of the mouth and the sublingual gland. (4) The deep lingual, which is the larger of the terminal branches and passes to

the tongue tip giving numerous branches to the dorsum. There is a rich anastomosis between various branches, although the vertical

septum of the tongue prevents any connection across the midline, except in the region of the posterior third and extreme tip (Carlesso et al., 1980). The excellent circulation (Fig. 2) ensures the vitality of lingual flaps is rarely compromised providing general surgical principles are followed.

One disadvantage with certain partial thickness tongue flaps, particularly those which are derived from the dorsum or are anteriorly based, is the restrictive tethering of the mobile tongue which is required whilst a new blood supply is established from the recipient site. There may be some concern also about the subsequent function and appearance of the tongue, particularly where large defects have to be restored, but all these problems are minimised when the posteriorly based, full thickness, lateral tongue flap is used.

This paper illustrates the versatility of this technique in oral reconstruction.

Surgical technique

Following the induction of general anaesthesia stay sutures are inserted to aid control of the tongue. The flap is outlined on the dorsal and ventral surfaces and designed in such a way as to preserve the tongue tip (Fig. 2). Approximately one

(Received 19 November 198 1; accepted 11 March 1982) *Present address: Maxillofacial Unit, Walton Hospital, Rice Lane, Liverpool 9 1AE.

1

2 BRITISH JOURNAL OF

Ext.

I kuprahyoid a. &blingual a.

LINGUAL ARTERY

Carotid a.

Figure l-Branches of the lingual artery.

third of the width of the tongue can be used,

ORAL SURGERY

Figure 2-Blood supply to the tongue. Note the lack of crossover in the middle portion due to the midline septum. The outline of the lateral tongue flap is also shown, together with the optional back-cut which is

used to obtain increased mobilisation.

and the base of the flap is placed as far posteriorly as the circumvallate line. If the anaesthetist agrees, two per cent lignocaine containing 1 :80,000 adrenaline is injected into the body of the tongue on the side from which the flap is to be raised. The theoretical objection of possible reactionary haemorrhage following this injection has not been encountered in prac- tice, and there are definite advantages as far as haemostasis is concerned, particularly if controlled hypotensive anaesthesia is not possible.

The tongue is divided with a No. 10 scalpel blade using the stay sutures to main-

Figure S-Full thickness division of the tongue to form a lateral flap.

VERSATILITY OF TONGUE FLAP IN RECONSTRUCTION DEFECTS 3

Figure 4-The initial incision and the flap opened out by a series of longitudinal incisions. tain tension (Fig. 3). Additional mobilisation of the flap can be obtained by judicious use of a back cut in which the longitudinal incision is angled laterally at the posterior end (Fig. 2). There is usually minimal bleeding, but care should be taken to control the vessels on the main body of the tongue prior to repair in layers. If fine monofilament suture material is used to reconstitute the mucosa it will cause less tissue reaction and remain cleaner than traditional silk sutures. Increased width can be obtained if required by dividing the muscle on the undersurface of the flap using short incisions in the longitudinal axis. Vascularity does not appear to be com- promised by this procedure which allows the flap to be ‘opened out’ to provide a considerable area of mucosal cover (Fig. 4).

Clinical applications

One well established indication for the use of a lateral tongue flap is the closure of large palatal fistulae (Figs. 5 & 6). The use of local tissue for this purpose is much more convenient than employing regional flaps or tube pedicles. Although the tongue is a mobile organ it does not drag on the flap, which has its base in the less mobile posterior one third. Interim mouth function is usually surprisingly good and feeding is not a problem if liquid or semi-solid diet is maintained. Naso-gastric feeding with a narrow bore tube is advised for the first few days, however, in order to allow initial healing to take place without contamination of the suture lines.

The pedicle is divided two to three weeks after the first operation, and endo- tracheal intubation is rarely difficult since the blade of the laryngoscope can easily be inserted to one side of the flap. Following division of the flap the base is inset into the side of the tongue and, if the tip has been preserved as recommended above, careful secondary repair will result in minimal deformity and excellent function (Fig. 7). The portion of the flap remaining attached to the palate is inset as necessary, and there is usually enough tissue to allow for considerable thinning if it is required.

The lateral tongue flap is also an excellent source of mucosal lining for other areas in the oral cavity, although this is less often appreciated. Klopp and Shurter (1956) were the first to describe reconstruction of the soft palate and tonsillar area using the longitudinally split tongue as a rotational pedicle, and other authors (Conley et al., 1957; Papaionnou & Farr, 1966; Ganguli, 1968; De Santo, 1974; Sessions et al., 1975) also realised the advantages of using this local flap to recon- struct defects of the cheek and floor of the mouth. It may be argued that the

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Figure anaesl

: 5-Case 1. (A) Large residual posterior fistula in an adult patient with cleft lip and palate. The :hetic tube isvisible through the fistula (B) Tongue flap inset into the anterior edge of the defect. (C)

Final result at completion of secondary operation. Further thinning is indicated later.

Figur

amc 3unt of regi .onal fla ava ilable :P mu1 ltiple inc

VERSATILITY OF TONGUE FLAP IN RECONSTRUCTION DEFECTS 5

‘e 6-C : 2 (A) Residual fistula following orthodontic expansion in a patient with bilateri Segments stabilised and tongue flap inset into defect. (C) Final result.

lining obtainable from the tongue flap is limited when compa .ps, such as the forehead flap, but a surprising area of mucosal roviding the muscle on the undersurface of the flap is divid’ :isions in the long axis as mentioned previously.

11 clef

.red with cot rer is

ed 1 lsing

t.(B)

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Figure 7-Case 2. (A) Secondary repair of the tongue at time of flap division. (B) Result three months later.

A major advantage in using a tongue flap to provide lining is the inherent elasticity of the lingual mucosa which has a texture similar to that of the tissue being replaced. Regional skin flaps, on the other hand, are relatively bulky and in- elastic, and have the disadvantage of leaving a visible donor site. Furthermore, in some cases, where the tongue flap has been used to reconstitute the floor of the mouth or buccal sulcus, it is often unnecessary to divide the base of the flap as a secondary procedure since function may be relatively unimpaired.

Three cases are illustrated which demonstrate the versatility of the tongue flap in the reconstruction of the lip, cheek and floor of the mouth.

The first is a patient who presented with tissue loss and fibrosis following cancnmr oris in childhood. This condition is still common in underdeveloped countries and the resultant area of extra-articular fibrous ankylosis requires a wide excision prior to reconstruction. In the case illustrated (Fig. 8) the disease had affected the angle of the mouth and upper lip with consequent exposure of the upper left cheek teeth. Following extraction of the periodontally involved teeth a full thickness resection of the cheek was performed to remove the fibrous tissue and release ankylosis. A lateral tongue flap provided excellent buccal lining (Fig.9A) prior to mobilising a delto-pectoral flap for skin cover (Fig. 9B).

In the fully dentate patient an interocclusal splint is required to prevent in- advertent biting of the flap, but if teeth have been extracted this is unnecessary (Fig. 9C). When the tongue flap and deltopectoral flap were divided and inset, advance- ment of a portion of the tongue flap mucosa allowed satisfactory reconstruction of the upper lip vermillion (Fig. 9D).

A tongue flap can be used to replace the floor of the mouth and vestibular region as shown in the case of a 28-year-old man who presented with a large ulcerated legion in the right mandibular retromolar region. Biopsy confirmed this to be an osteosarcoma and it was excised, together with the right hemimandible and wide area of surrounding soft tissue (Fig. 1OA). When opened out, a tongue flap provided a ready means of reconstructing the oral floor and adjacent cheek. A deltopectoral flap was used for skin cover (Fig. 10B) and secondary division of the tongue proved unnecessary in this case (Fig. 11).

In the final case the patient had an en bloc resection for carcinoma of the left mandible. A tongue flap was used to reconstitute the floor of the mouth and to prevent tongue tethering (Fig. 12A & B). As can be seen a surprising amount of tissue may be obtained when the flap is opened out.

VERSATILITY OF TONGUE FLAP IN RECONSTRUCTION DEFECTS 7

Figure g--Case 3. Loss of part of upper lip and cheek as a result of cancrum oris, with severe restriction of mouth opening.

Figure 9-Case 3. (A) Scar tissue widely excised and lateral tongue flap opened out to line defect. (arrows). (B) Delpectoral flap providing skin cover to cheek defect. (C) Intra-oral view of tongue flap prior to secondary operation. Note lack of interference with tongue mobility. (D) Result at the end of secondary operation. Part of the tongue flap mucosa has been advanced to reconstruct upper lip vermilion.

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Figure IO-Case 4. (A) Defect following excision of osteosarcoma of mandible. (B) Primary repair using tongue flap and delpectoral flap. (C) Final result.

Figure 1 l--Case 4. Tongue flap in situ (arrow). Mouth function was adequate without secondary division of the base of flap.

VERSATILITY OF TONGUE FLAP IN RECONSTRUCTION DEFECTS 9

Figure 12-Case 5. (A) Defect following en bloc resection for carcinoma of left mandibular alveolus. Tongue flap outlined and lingual artery temporarily occluded with bull-dog clip. (B) Floor of mouth

reconstructed with ‘spread’ tongue flap.

Discussion

The technique and indications for using the lateral tongue flap have been discussed and illustrated. It has the obvious advantage of obviating the need for two regional skin flaps in the reconstruction of full thickness defects, and the poor cosmetic results obtained with forehead flaps are also avoided. It also provides a versatile answer to the problem of large palatal fistulae, such as may occur in some cases of cleft palate or following trauma.

The excellent blood supply to the tongue means that few complications occur, and it is maintained that the abundant collateral circulation allows ligation of the ipsilateral lingual artery without impairing flap vitality (Klopp & Shurter, 1956; Chambers et al., 1969). Necrosis of the distal part of the flap, and of the remaining tongue tip, has been reported (Papaionnou & Farr, 1966; Chambers et al., 1969) although careful flap design should minimise this possibility. There is an increase in complications following irradiation however, and tongue flap reconstruction is probably contra-indicated in this instance (Sessions et al., 1975).

Experience with using the full thickness lateral tongue flap has confirmed that it is a versatile means of providing local tissue to reconstruct defects of the lip, cheek, floor of the mouth and palate.

Acknowledgements

We wish to thank Mr Peter Banks, Consultant Oral and Maxillo-Facial Surgeon, Queen Victoria Hospital, East Grinstead for allowing us to report on the two cleft palate cases with residual fistulae.

References

Bakamjian, V. Y. (1964). The use of tongue flaps in lower lip reconstruction. British Journal of Plastic Surgery, 17, 19 1.

Carlesso, J., Mondolfi, P. & Enrique, F. (1980). Hemi-tongue flaps. Plastic and Reconsfructive Surgery, 66,574.

Chambers, R. G., Jacques, D. A. & Mahoney, W. D. (1969). Tongue flaps for intra-oral reconstruction. American Journal of Surgery, 118,183.

Conley, J. J., De Amest, F. & Pierce, M. K. (1957). The use of tongue flaps in head and neck surgery. Surgery, 41, 745.

Converse, J. M. (1977). Reconstructive plastic surgery, London : Saunders.

2nd Ed. Pp. 2702-2703. Philadelphia &

De Santo, L. W. (1974). Lingual flap reconstruction after resection for cancer. Transactions of the American Academy of Ophthalmology and Otolaryngology, 78, 135.

Ganguli, A. (1968). Use of tongue flap to line cheek defects in surgery for cancer. Plastic and Reconstructive Surgery, 41, 390.

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Guerrero-Santos, J. & Altamirano, J. T. (1966). The use of lingual flaps in repair of fistulas of the hard and soft palate. Plastic and Reconstructive Surgery, 38,123.

Jackson, I. T. (1972a). Use of tongue flaps to resurface lip defects and close palatal fistulae in children. Plastic and Reconstructive Surgery, 49, 537.

Jackson, I. T. (1972b). Closure of secondary palatal fistulae with intra-oral tissue and bone grafting. British Journal of Plastic Surgery, 25,93.

Klopp, C. T. & Shurter, M. (1956). The surgical treatment of cancer of the soft palate and tonsil. Cancer, 9, 1239.

McGregor, I. A. (1966). The tongue flap in lip surgery. British Journal of Plastic Surgery, 19,253. Papaionnou, A. N. & Farr, H. W. (1966). Reconstruction of the floor of the mouth by a pedicle tongue

flap. Surgery, Gynecology and Obstetrics, 122,807. Sessions, D. G., Dedo, D. D. & Ogura, J. H. (1975). Tongue flap reconstruction in cancer of the oral

cavity. Archives of Otolaryngology, 101, 166.