|Year : 2017 | Volume
| Issue : 3 | Page : 78-83
The use of tongue flaps in primary cleft palate repair
Navin Vig1, Atheer Ujam2, Hamza Elburi3
1 Centre for Cell Biology, Blizard Institute, Queen Mary, University of London, London, England
2 Great Ormond Street Institute of Child Health, University College London, London, England
3 Misurata Cancer Centre, Misurata; International Centre for Otorhinolaryngology, Misurata, Libya
|Date of Web Publication||21-Nov-2017|
Blizard Institute, 4 Newark Street, London, UK E1 2AT
Source of Support: None, Conflict of Interest: None
The tongue flap, for the reconstruction of oral defects, was first described over one hundred years ago. They have since been used to manage a variety of defects and have proved to be reliable and predictable. We report our preliminary experience with the use of the anterior-based pedicle tongue flap for primary repair of wide palatal clefts in Libyan infants. The repair was associated with good structural closure of the defect and was free of any major complications. Given the current limitations in Libya, we have used this method for wide palatal cleft defects in the absence of standard support from a multi-disciplinary team. Our initial results look promising.
Keywords: Cleft, flap, palate, tongue
|How to cite this article:|
Vig N, Ujam A, Elburi H. The use of tongue flaps in primary cleft palate repair. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:78-83
|How to cite this URL:|
Vig N, Ujam A, Elburi H. The use of tongue flaps in primary cleft palate repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2019 Jun 19];4, Suppl S1:78-83. Available from: http://www.jclpca.org/text.asp?2017/4/3/78/218890
| Introduction|| |
The complex nature, and treatment, of the oral cleft necessitates management under a highly specialized multidisciplinary team (MDT) from the early stages of life through to adulthood. Surgical treatment is supported by a host of professionals to optimize function, growth, and emotional well-being. However, in certain environments, such as conflict zones such as Libya or in parts of the developing world, the full MDT is not always available requiring alternative treatment strategies to be developed. One such alternative surgical strategy is the anterior-based dorsal tongue flap to treat patients with isolated cleft palates (cleft palate only [CPO]). Established cleft palate surgical techniques are associated with reduced maxillary growth secondary to scarring and potentially bony regeneration. This technique may limit both and therefore encourage a more normal maxillary growth pattern.
The tongue flap has been used for oral and maxillofacial reconstruction for well over a century. Its use was first described by Eiselsberg in 1901, who used a pedicled flap to reconstruct intraoral defects, and later by Lexer in 1909, who reported the use of a tongue flap to manage defects of the retromolar and tonsillar region. It was later reintroduced by Klopp and Schurter in 1956. Guerrero-Santos and Altamirano published their experience of using dorsal tongue flaps to close palatal defects, including clefts, in 1966. Since then, it has become increasingly popular, widely used for reconstruction of oral defects. A number of tongue flaps are now described, including the dorsal, ventral, lateral, median transit, sliding, and island tongue flaps.,,,
Anatomically, the tongue has a rich vascular supply. This is predominantly from the lingual artery which branches into the dorsal lingual, deep lingual, and sublingual arteries. It also has a secondary supply from the tonsillar branch of the facial artery and the ascending pharyngeal artery. Consequently, the blood supply is abundant with a rich submucous plexus of vessels on the dorsum of the tongue that provides an excellent site to raise either a dorsal or anterior-based flap.
The dorsal tongue flap is based on the dorsal lingual artery. The flap can be positioned posteriorly or anteriorly depending on the location of the intraoral defect. Posterior-based tongue flaps are deemed to have a more robust blood supply as the arterial supply feeds the tongue from posterior to anterior, which increases their predictability in theory. However, their use can be limited due to lack of mobility and the position of the circumvallate papillae, elevation past which may compromise the blood supply of the flap. It can be considered for defects of the retromolar and tonsillar regions, posterior hard and soft palate, and posterior buccal mucosa.
The anterior-based tongue flap, based on the rich dorsal submucous plexus of vessels, is considered to be the most versatile of all tongue flaps given its relative mobility. As well as palatal clefts described in this paper, it can be used to reconstruct palatal defects, anterior buccal mucosa defects, and floor of mouth and lip defects. The robust perfusion of the tongue significantly improves the likelihood of success of the pedicled tongue flap. However, a number of important steps may further enhance its success. When raising a dorsal flap, it is essential to include some intrinsic muscle with the mucosa to ensure an adequate blood supply. In adults, it is recommended that the flap is no >10 mm in thickness as this may impact on postoperative function. The length of the flap should be sufficient to limit tension and the base sufficiently wide to reduce the chance of flap necrosis. Care should be taken to avoid the circumvallate papillae and to preserve the tip of the tongue as much as possible.
We present our experience of pediatric cleft palate cases treated with the tongue flap and demonstrate using examples, our surgical outcomes. The results have been most gratifying given the challenges of operating in an area of conflict and limited resources.
| Methods|| |
A total of 24 children from Libya, with an isolated cleft palate, were treated between August 2015 and August 2017. Procedures were carried out by a single surgeon, in Misurata, Libya. The age of patients ranged between 6 months and 14 years, but the majority (n = 22) were <9 months old at the time of surgery. Two children were older, aged 7 and 14 years, respectively.
For the anterior-based tongue flap for the pediatric CPO patient, a standard surgical protocol was established. This includes preoperative patient preparation, standardized surgical technique, and well-defined postoperative care pathway. Consent for surgery was obtained from parents following detailed consultation regarding the procedure, its complications, and benefits. Parents were informed that a second stage procedure under general anesthetic was required that to divide the tongue flap. Ethical approval was sought, and obtained, from the Directorate of the Hospital in Misurata where all the patients were treated.
It is essential to have a skilled anesthetist with experience in pediatric and neonatal anesthesia. To ensure adequate access and visibility, nasoendotracheal intubation is preferred. It was accomplished in all our patients for both stage 1 and 2 of the tongue flap. During anesthesia for the 2nd stage, the attached tongue pedicle can pose an anesthetic challenge. If serious intubation difficulties are anticipated, the pedicle can be divided during the induction phase and procedure completed after successful oral intubation.
Preparation of palatal recipient bed
A Vomer flap is raised, reflected bilaterally to advance laterally. Lateral palatine flaps are raised by incisions made lateral to edge of the palatal shelf. Tissue is freed from nasal surface of palate and edges advanced medially to join the Vomer flap on each side. The edges of the palatal defect are undermined to provide a good margin for reception of tongue flap.
Raising the anterior-based tongue flap
The flap is delineated with a marking pen [Figure 1]. The cleft length dictates its length, and the flap should sit passively. The width should be slightly greater than the cleft defect and the depth of the flap should be approximately 3 mm, to include intrinsic muscle, which may deepen to 5 mm toward the base.
Up to 2/3 of the dorsal surface may be used without significant tongue deformity. Care must be taken not to extend the flap too close to the circumvallate papillae or the tip of the tongue. Adequate hemostasis is maintained throughout with bipolar diathermy.
Insetting the flap
The flap is positioned within the defect, ensuring it sits passively [Figure 2]. It is sutured into the reception site with a 4.0 resorbable suture, anteriorly and laterally. Care should be taken to avoid sutures through the muscular flap as these might compromise the blood supply. The donor site is closed with 4.0 resorbable suture taking care not to constrict the pedicle base.
This is the 2nd stage of the process and normally occurs 2–3 weeks after the 1st stage to allow for neovascularization [Figure 3]. It is performed under general anesthesia after nasoendotracheal intubation. The flap is divided posteriorly at a position that will allow adequate reconstruction of the remaining defect. Closure is achieved with a 4.0 resorbable suture [Figure 4]. The donor site can be sutured and modified to achieve an esthetic and functional dorsal surface [Figure 5].
|Figure 4: The tongue flap is divided at the base of the pedicle and sutured to the palate to complete the closure|
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|Figure 5: After flap division, the donor site is closed easily and restores full function and esthetics of the tongue|
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With regard to surgical technique, there are a few potential complications. Intubation may give rise to difficulties particularly at the 2nd stage of the procedure. This necessitates working together with an experienced anesthetist. Flap design is important, as ensuring that the flap length, thickness, and base width are adequate requires sound judgment and operator skill, often achieved through a steep learning curve. Postoperatively, edema (of the tongue) is expected, and close monitoring is advised. Patients may benefit from intravenous steroids. Bleeding may occur from the donor or flap site, or a hematoma of the tongue may develop, making adequate hemostasis essential throughout.
Flap dehiscence, detachment, or necrosis is uncommonly seen and was not seen in our cohort. It is likely to be due to poor flap design or inadequate fixation. The flap should be of sufficient length so as not be under tension and be of adequate thickness to ensure a good blood supply and care should be taken with rotation of the flap. Poor compliance is normally an issue with adults, but in this cohort, the flap was well tolerated. Postoperative feeding was not an issue. Children were able to return to oral feeding within a short period of time. With regard to donor-site morbidity, this is more limited than one would think. The length of the tongue is not reduced, and although the tongue narrows, it has no impact on function particularly as the tip is unaffected.
Postoperative care and advice
Parents are given instruction on diet and oral hygiene for their child as well as analgesia requirements. They are reassured that the procedure, despite the appearance, will be well tolerated.
| Results and Follow-Up|| |
The procedure was well tolerated by our patients, and our outcomes demonstrate excellent healing both short and long term. None of our patients had premature flap dehiscence or necrosis and there were no complications at the tongue donor site. There have been no problems with tongue function postoperatively, and parents have reported no problems with feeding. There have been no palatal fistulae reported. For the two older patients treated (aged 7 and 14 years), speech was reported to have improved, but this will be assessed more formally.
The cohort of patients included in this case series is in the relatively early postoperative stage. A more comprehensive picture of their outcomes will become available as they are followed up and reviewed in the areas outlined below:
- Speech and language: speech therapy to begin at 18 months
- Maxillary growth and dental arches monitoring using standard parameters
- Hearing and Eustachian tube More Details function
- Psychological status (where possible).
| Discussion|| |
Oral clefts, involving the lip and/or the palate, are the most common craniofacial birth anomalies. As already well described, prevalence varies among ethnic groups, with the highest prevalence in those of Asian extraction. In Libya, a large number of cleft palates are seen always readily conforming to standard classification techniques, with many wide, isolated palatal clefts.
The isolated cleft palate (CPO) is the least common form of oral clefting, approximately one-third of all clefts. The highest rates of CPO are seen in those of European extraction, at approximately 6–14 per 10,000 live births, with children of African extraction again with the lowest rates at 0.32–4 per 10,000., Half of patients with CPO have an associated syndrome, as opposed to 30% of children with CLP. Females are slightly more likely to be affected than males with a female to male sex ratio of 1.07.,
The cleft palate may be seen alone or involve the lip, be unilateral or bilateral, complete or incomplete. If incomplete, it can be limited to the soft palate or involved both soft and hard palate. A submucous cleft palate describes a cleft with intact mucosal tissue, other than a cleft uvula, but disrupted musculature as seen in a complete cleft.
Surgical treatment aims to restore functional deficits in feeding, speech, and hearing and to optimize growth and subsequent facial cosmesis. Palatal closure is arguably the most important aspect of cleft surgery. It seeks to separate the oral and nasal cavity, to create a competent velopharyngeal valve for normal speech and swallowing, and to maximize facial growth and development of the dentition.
Under ideal circumstances, any surgical intervention for these patients is performed in coordination with the multidisciplinary team that normally consists of plastic/maxillofacial/ENT surgeons, specialist nurses, speech therapists, audiologists, psychologists, dentists, and orthodontists. However, given the current environment in Libya, many of these specialist services are limited or completely absent. Newer techniques that aim to reduce the number of surgical interventions required (such as gingivo-periosteoplasty, pre-surgical orthopedics, nasoalveolar molding, and external strapping) are either unavailable or severely restricted.
The tongue flap is one of these alternative approaches. Eiselsberg used the flap to correct cleft defects, as have others since, but follow-up and outcomes for this particular aspect were poorly documented. Nevertheless, its use for reconstruction of oral defects has been widely described, and the flap is commonly used particularly for the closure of palatal fistulae. Coghlan et al. described its use for the closure of palatal fistulae in cleft patients after maxillary advancement osteotomies with good results. Its use for the closure of CPO is not widespread given alternative and established techniques but it has advantages where these are not available. The procedure is relatively straightforward and complication-free. Short-term outcomes have been extremely positive, with subsequent benefit to the child's health. Many cleft surgeons also seek to correct the velar musculature, through the intravelar veloplasty, when repairing the palate. Although the evidence to support this procedure is equivocal, use of the tongue flap does not preclude later surgery to address the velar muscular sling which will be performed once speech therapy begins.
However, established cleft repair techniques are not without their drawbacks. The type of repair that is performed depends upon the preference, experience, and training of the surgeon, as limited evidence exists to support one procedure over another. It has been shown that a surgical repair using established techniques leads to reduced maxillary growth and maxillary retrusion. Most adults with unrepaired clefts do not experience impairment of maxillary growth, demonstrating the inhibitory role on growth that surgery plays.
This might be due to midline scarring that prevents normal growth but there might also be another reason. Palatal mucoperiosteum, mobilized and approximated in the established techniques, leads to bone regeneration from the cleft-free palatal shelves., This is predictable given the nature of the tissue. Although bone regeneration does not always occur along the entirety of the cleft, evidence indicates that where bony union occurs across the cleft, it plays a critical role in the impairment of maxillary growth.
Together with midline scar bands, the bone generated by the palatal mucoperiosteal tissue may act to reduce the very growth required for normal health and well-being at a later stage in life, often requiring significant clinical input to correct. Consequently, the use of mucosal tissue, provided by the tongue flap, might be beneficial to maxillary growth and development, not a hindrance. Obviously, longer-term follow-up of our patients will determine whether this is so but current understanding of the causes of maxillary growth restriction after cleft palate surgery would support this premise.
| Conclusions|| |
The tongue flap is well known for the reconstruction of oral defects. Here, it is employed to treat infants with isolated cleft palates, with promising early results. With longer follow-up, key patient outcomes will become more apparent. The relative simplicity of this technique and its potential advantages over more established techniques make it an ideal solution where resources are more limited. We advocate the use of the tongue flap for isolated cleft palate patients as it offers a reliable reconstructive solution to a complex surgical problem.
We would like to thank Mr. N A Nasser, Consultant Oral and Maxillofacial Surgeon, for his inspiration, guidance, and images in this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]