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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Posteriorly based lateral tongue flap for reconstruction of large palatal-alveolar fistulas in cleft patients</title><author><name sortKey="Rahpeyma, Amin" sort="Rahpeyma, Amin" uniqKey="Rahpeyma A" first="Amin" last="Rahpeyma">Amin Rahpeyma</name><affiliation><nlm:aff id="aff1">Oral and Maxillofacial Diseases Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</nlm:aff></affiliation></author><author><name sortKey="Khajehahmadi, Saeedeh" sort="Khajehahmadi, Saeedeh" uniqKey="Khajehahmadi S" first="Saeedeh" last="Khajehahmadi">Saeedeh Khajehahmadi</name><affiliation><nlm:aff id="aff2">Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26981466</idno><idno type="pmc">4772556</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772556</idno><idno type="RBID">PMC:4772556</idno><idno type="doi">10.4103/2231-0746.175767</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000608</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000608</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Posteriorly based lateral tongue flap for reconstruction of large palatal-alveolar fistulas in cleft patients</title><author><name sortKey="Rahpeyma, Amin" sort="Rahpeyma, Amin" uniqKey="Rahpeyma A" first="Amin" last="Rahpeyma">Amin Rahpeyma</name><affiliation><nlm:aff id="aff1">Oral and Maxillofacial Diseases Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</nlm:aff></affiliation></author><author><name sortKey="Khajehahmadi, Saeedeh" sort="Khajehahmadi, Saeedeh" uniqKey="Khajehahmadi S" first="Saeedeh" last="Khajehahmadi">Saeedeh Khajehahmadi</name><affiliation><nlm:aff id="aff2">Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</nlm:aff></affiliation></author></analytic><series><title level="j">Annals of Maxillofacial Surgery</title><idno type="ISSN">2231-0746</idno><idno type="eISSN">2249-3816</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background:</title><p>Large palatal fistula in cleft patients is a difficult situation, especially with previous multiple surgeries, which have led to severe scars in the palatal mucosa. Tongue flaps are useful aids in such situations.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>Seven cleft patients who were reconstructed by posteriorly based lateral tongue flap between 2005 and 2012 were studied. Variables such as flap-ability to close the fistula, remaining tongue shape at least 1 year after operation, and speech improvement (patients’ self-assessment) were evaluated.</p></sec><sec id="st3"><title>Results:</title><p>Age range of the patients was 14‒45 years. The male-to-female ratio was 2/7. Posteriorly based lateral tongue flap effectively closed the large fistula in 6/7 of patients. The largest dimensions of fistula closed by this flap was 5 cm × 1.5 cm. Follow-up of 2‒7 years showed that the tongue never returned to the original size and remained asymmetrical. In addition, the nasal speech did not improve dramatically after the closure of large palatal/alveolar fistulas in this age group.</p></sec><sec id="st4"><title>Conclusion:</title><p>Posteriorly based lateral tongue flap is an effective method to solve the problem of large palatal fistulas in adult cleft patients. The most useful indication for this flap is a large longitudinal palatal fistula, extending to the alveolar process. Asymmetrical tongue shape after surgery is the rule and speech improvement depends on patient's age and location of fistula.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Murthy, J" uniqKey="Murthy J">J Murthy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Benateau, H" uniqKey="Benateau H">H Bénateau</name></author><author><name sortKey="Traore, H" uniqKey="Traore H">H Traoré</name></author><author><name sortKey="Gilliot, B" uniqKey="Gilliot B">B Gilliot</name></author><author><name sortKey="Taupin, A" uniqKey="Taupin A">A Taupin</name></author><author><name sortKey="Ory, L" uniqKey="Ory L">L Ory</name></author><author><name sortKey="Guillou Jamard, Mr" uniqKey="Guillou Jamard M">MR Guillou Jamard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Charan Babu, Hs" uniqKey="Charan Babu H">HS Charan Babu</name></author><author><name sortKey="Bhagvandas Rai, A" uniqKey="Bhagvandas Rai A">A Bhagvandas Rai</name></author><author><name sortKey="Nair, Ma" uniqKey="Nair M">MA Nair</name></author><author><name sortKey="Meenakshi" uniqKey="Meenakshi">Meenakshi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Al Qattan, Mm" uniqKey="Al Qattan M">MM Al-Qattan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Posnick, Jc" uniqKey="Posnick J">JC Posnick</name></author><author><name sortKey="Getz, Sb" uniqKey="Getz S">SB Getz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Butow, Kw" uniqKey="Butow K">KW Bütow</name></author><author><name sortKey="Duvenage, Jg" uniqKey="Duvenage J">JG Duvenage</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ceran, C" uniqKey="Ceran C">C Ceran</name></author><author><name sortKey="Demirseren, Me" uniqKey="Demirseren M">ME Demirseren</name></author><author><name sortKey="Sarici, M" uniqKey="Sarici M">M Sarici</name></author><author><name sortKey="Durgun, M" uniqKey="Durgun M">M Durgun</name></author><author><name sortKey="Tekin, F" uniqKey="Tekin F">F Tekin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Yk" uniqKey="Kim Y">YK Kim</name></author><author><name sortKey="Yeo, Hh" uniqKey="Yeo H">HH Yeo</name></author><author><name sortKey="Kim, Sg" uniqKey="Kim S">SG Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Buchbinder, D" uniqKey="Buchbinder D">D Buchbinder</name></author><author><name sortKey="St Hilaire, H" uniqKey="St Hilaire H">H St-Hilaire</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Johnson, Pa" uniqKey="Johnson P">PA Johnson</name></author><author><name sortKey="Banks, P" uniqKey="Banks P">P Banks</name></author><author><name sortKey="Brown, Ae" uniqKey="Brown A">AE Brown</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kinnebrew, Mc" uniqKey="Kinnebrew M">MC Kinnebrew</name></author><author><name sortKey="Malloy, Rb" uniqKey="Malloy R">RB Malloy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vaughan, Ed" uniqKey="Vaughan E">ED Vaughan</name></author><author><name sortKey="Brown, Ae" uniqKey="Brown A">AE Brown</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Deshmukh, A" uniqKey="Deshmukh A">A Deshmukh</name></author><author><name sortKey="Kannan, S" uniqKey="Kannan S">S Kannan</name></author><author><name sortKey="Thakkar, P" uniqKey="Thakkar P">P Thakkar</name></author><author><name sortKey="Chaukar, D" uniqKey="Chaukar D">D Chaukar</name></author><author><name sortKey="Yadav, P" uniqKey="Yadav P">P Yadav</name></author><author><name sortKey="D Ruz, A" uniqKey="D Ruz A">A D’Cruz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kummer, Aw" uniqKey="Kummer A">AW Kummer</name></author><author><name sortKey="Neale, Hw" uniqKey="Neale H">HW Neale</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Guzel, Mz" uniqKey="Guzel M">MZ Guzel</name></author><author><name sortKey="Altintas, F" uniqKey="Altintas F">F Altintas</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Assuncao, Ag" uniqKey="Assuncao A">AG Assunçao</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Mj" uniqKey="Kim M">MJ Kim</name></author><author><name sortKey="Lee, Jh" uniqKey="Lee J">JH Lee</name></author><author><name sortKey="Choi, Jy" uniqKey="Choi J">JY Choi</name></author><author><name sortKey="Kang, N" uniqKey="Kang N">N Kang</name></author><author><name sortKey="Lee, Jh" uniqKey="Lee J">JH Lee</name></author><author><name sortKey="Choi, Wj" uniqKey="Choi W">WJ Choi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Barone, Cm" uniqKey="Barone C">CM Barone</name></author><author><name sortKey="Argamaso, Rv" uniqKey="Argamaso R">RV Argamaso</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Coghlan, K" uniqKey="Coghlan K">K Coghlan</name></author><author><name sortKey="O Egan, B" uniqKey="O Egan B">B O’Regan</name></author><author><name sortKey="Carter, J" uniqKey="Carter J">J Carter</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pigott, Rw" uniqKey="Pigott R">RW Pigott</name></author><author><name sortKey="Rieger, Fw" uniqKey="Rieger F">FW Rieger</name></author><author><name sortKey="Moodie, Af" uniqKey="Moodie A">AF Moodie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Morel, M" uniqKey="Morel M">M Morel</name></author><author><name sortKey="Danino, A" uniqKey="Danino A">A Danino</name></author><author><name sortKey="Malka, G" uniqKey="Malka G">G Malka</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Busic, N" uniqKey="Busic N">N Busic</name></author><author><name sortKey="Bagatin, M" uniqKey="Bagatin M">M Bagatin</name></author><author><name sortKey="Boric, V" uniqKey="Boric V">V Boric</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Argamaso, Rv" uniqKey="Argamaso R">RV Argamaso</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Elyassi, Ar" uniqKey="Elyassi A">AR Elyassi</name></author><author><name sortKey="Helling, Er" uniqKey="Helling E">ER Helling</name></author><author><name sortKey="Closmann, Jj" uniqKey="Closmann J">JJ Closmann</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lahiri, A" uniqKey="Lahiri A">A Lahiri</name></author><author><name sortKey="Richard, B" uniqKey="Richard B">B Richard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nakakita, N" uniqKey="Nakakita N">N Nakakita</name></author><author><name sortKey="Maeda, K" uniqKey="Maeda K">K Maeda</name></author><author><name sortKey="Ando, S" uniqKey="Ando S">S Ando</name></author><author><name sortKey="Ojimi, H" uniqKey="Ojimi H">H Ojimi</name></author><author><name sortKey="Utsugi, R" uniqKey="Utsugi R">R Utsugi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Murthy, J" uniqKey="Murthy J">J Murthy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Der Wal, Kg" uniqKey="Van Der Wal K">KG van der Wal</name></author><author><name sortKey="Mulder, Jw" uniqKey="Mulder J">JW Mulder</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ninkovic, M" uniqKey="Ninkovic M">M Ninkovic</name></author><author><name sortKey="Hubli, Eh" uniqKey="Hubli E">EH Hubli</name></author><author><name sortKey="Schwabegger, A" uniqKey="Schwabegger A">A Schwabegger</name></author><author><name sortKey="Anderl, H" uniqKey="Anderl H">H Anderl</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Ann Maxillofac Surg</journal-id><journal-id journal-id-type="iso-abbrev">Ann Maxillofac Surg</journal-id><journal-id journal-id-type="publisher-id">AMS</journal-id><journal-title-group><journal-title>Annals of Maxillofacial Surgery</journal-title></journal-title-group><issn pub-type="ppub">2231-0746</issn><issn pub-type="epub">2249-3816</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26981466</article-id><article-id pub-id-type="pmc">4772556</article-id><article-id pub-id-type="publisher-id">AMS-5-174</article-id><article-id pub-id-type="doi">10.4103/2231-0746.175767</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article - Retrospective Study</subject></subj-group></article-categories><title-group><article-title>Posteriorly based lateral tongue flap for reconstruction of large palatal-alveolar fistulas in cleft patients</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Rahpeyma</surname><given-names>Amin</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Khajehahmadi</surname><given-names>Saeedeh</given-names></name><xref ref-type="aff" rid="aff2">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib></contrib-group><aff id="aff1">Oral and Maxillofacial Diseases Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</aff><aff id="aff2"><label>1</label>Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Saeedeh Khajehahmadi, Dental Research Center, School of Dentistry, Mashhad University of Medical Sciences, P. O. Box: 91735-984, Vakilabad Blvd, Mashhad, Iran. E-mail: <email xlink:href="khajehahmadis@mums.ac.ir">khajehahmadis@mums.ac.ir</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jul-Dec</season><year>2015</year></pub-date><volume>5</volume><issue>2</issue><fpage>174</fpage><lpage>178</lpage><permissions><copyright-statement>Copyright: © 2015 Annals of Maxillofacial Surgery</copyright-statement><copyright-year>2015</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.</license-p></license></permissions><abstract><sec id="st1"><title>Background:</title><p>Large palatal fistula in cleft patients is a difficult situation, especially with previous multiple surgeries, which have led to severe scars in the palatal mucosa. Tongue flaps are useful aids in such situations.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>Seven cleft patients who were reconstructed by posteriorly based lateral tongue flap between 2005 and 2012 were studied. Variables such as flap-ability to close the fistula, remaining tongue shape at least 1 year after operation, and speech improvement (patients’ self-assessment) were evaluated.</p></sec><sec id="st3"><title>Results:</title><p>Age range of the patients was 14‒45 years. The male-to-female ratio was 2/7. Posteriorly based lateral tongue flap effectively closed the large fistula in 6/7 of patients. The largest dimensions of fistula closed by this flap was 5 cm × 1.5 cm. Follow-up of 2‒7 years showed that the tongue never returned to the original size and remained asymmetrical. In addition, the nasal speech did not improve dramatically after the closure of large palatal/alveolar fistulas in this age group.</p></sec><sec id="st4"><title>Conclusion:</title><p>Posteriorly based lateral tongue flap is an effective method to solve the problem of large palatal fistulas in adult cleft patients. The most useful indication for this flap is a large longitudinal palatal fistula, extending to the alveolar process. Asymmetrical tongue shape after surgery is the rule and speech improvement depends on patient's age and location of fistula.</p></sec></abstract><kwd-group><kwd>Palatal fistula</kwd><kwd>reconstruction</kwd><kwd>tongue flap</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>INTRODUCTION</title><p>Reconstruction of large palatal fistulas in cleft patients is often extremely challenging.[<xref rid="ref1" ref-type="bibr">1</xref>] Because of adjacent mucosal atrophy and insufficient volume, closure of large fistulas is too difficult.[<xref rid="ref2" ref-type="bibr">2</xref>] Tongue flaps are appropriate techniques in such situations.[<xref rid="ref3" ref-type="bibr">3</xref>] The replaced tissue is mucosa therefore, it is an ideal reconstruction: “Replacement of the lost tissue with the similar tissue.” Tongue flaps have many variants, including anteriorly, or posteriorly based flaps with axial or random pattern blood supply from dorsal, ventral or lateral portion of the tongue.[<xref rid="ref4" ref-type="bibr">4</xref><xref rid="ref5" ref-type="bibr">5</xref><xref rid="ref6" ref-type="bibr">6</xref><xref rid="ref7" ref-type="bibr">7</xref>] Tongue flaps can be used in the reconstruction of the oral cavity in cleft surgery, congenital deformities, and intraoral reconstructions after pathologic resections or traumatic avulsions. It has been reported as a mucosal coverage for reconstruction of ramus, angle, body and symphysis of the mandible, floor of the mouth, soft and hard palate, maxillary alveolar region, oronasal and oroantral fistula closure, and buccal mucosal replacement. Lower lip and even the tongue itself can be reconstructed by this flap.[<xref rid="ref8" ref-type="bibr">8</xref><xref rid="ref9" ref-type="bibr">9</xref>]</p><p>Posteriorly based lateral tongue flap is an appropriate flap for reconstruction of large palatal and alveolar fistulas.[<xref rid="ref10" ref-type="bibr">10</xref>] The experience of the authors in this study about this flap in cleft patients is explained.</p></sec><sec sec-type="materials|methods" id="sec1-2"><title>MATERIALS AND METHODS</title><p>Seven cleft patients who underwent reconstruction by posteriorly based lateral tongue flap between 2005 and 2012 were studied. Variables such as flap's ability to close the fistula, the remaining tongue shape at least 1 year after surgery, and speech improvement (patient's self-assessment and parents’ opinion) were evaluated. The surgical procedure was as follows:</p><sec id="sec2-1"><title>Preparation of the recipient site</title><p>The two-layer closure is the goal of this surgery. Nasal-side closure is often achieved by turning over the palatal mucosa on the edges and suturing together in the midline (hinged flap). In cases where the nasal septum was accessible through the fistula, elevating the mucosa from one side of this structure was useful (vomer flap). In a case the inferior turbinate was used as anteriorly based mucosal flap, it was sutured to the edges of the reflected palatal mucosa to provide nasal floor sill [<xref ref-type="fig" rid="F1">Figure 1</xref>].</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>(a) Palatal fistula at the junction of primary and secondary palate. Inferior turbinate is visible through the fistula. (b) Anteriorly based inferior turbinate flap was used to assist in the nasal-side closure. (c) Palatal fistula with visible nasal septum through it. (d) Hinged flap from inversion of adjacent palatal mucosa and vomer flap</p></caption><graphic xlink:href="AMS-5-174-g001"></graphic></fig></sec><sec id="sec2-2"><title>Preparation of the donor site</title><p>Based on the location of the fistula, the incision design on the tongue differs. In maxillary alveolar process fistula extending posteriorly to the hard palate, the incision in the midline of the tongue tip was considered for the beginning of flap elevation. If the fistula was limited to the hard palate, the incision began one centimeter away from the tongue midline because of the need for less length. Based on the width of the defect, up to 1/3 of the tongue width could be included in the flap design. Full-thickness incision of the tongue from the anterior to the posterior direction creates posteriorly based lateral tongue flap. In such cases, the flap should not extend posteriorly to the circumvalate papilla. Great caution was exercised so that the flap pedicle would not become thin when the incision extended posteriorly [<xref ref-type="fig" rid="F2">Figure 2</xref>].</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>Posteriorly based lateral tongue flap. Note preservation of the tongue tip</p></caption><graphic xlink:href="AMS-5-174-g002"></graphic></fig><p>When there was a need for more width, the elevated flap could be incised from below in longitudinal direction. It converted the thick, narrow flap to a thin wide one. The flap was sutured to the recipient palatal mucosa. For further augmentation, one bone suture on each side of the fistula, in intact bone was applied for suspending the flap to aid in better tolerance of flap weight [<xref ref-type="fig" rid="F3">Figure 3</xref>].</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>(a) Schematic representation. Two bone sutures are used for suspension of the tongue flap. (b and c) Posteriorly based lateral tongue flap in place</p></caption><graphic xlink:href="AMS-5-174-g003"></graphic></fig></sec><sec id="sec2-3"><title>Pedicle division</title><p>All the flaps were divided 3 weeks after the first surgical operation. The remaining tongue pedicle was not returned to its original site in three cases and the muscular part of the pedicle was used for correction of the whistle deformity as free muscle transfer and the mucosal part for vestibuloplasty in anterior maxillary region to release the adhesion between the upper lip and premaxilla or to cover the denuded area after midline frenectomy. The proximal part of the pedicle was returned to the donor site in the other four cases. If fistula remained between the flap and the palate, then Z-plasty and pedicled flap from the transferred tongue flap were used to interdigitate these tissues [<xref ref-type="fig" rid="F4">Figure 4</xref>].</p><fig id="F4" position="float"><label>Figure 4</label><caption><p>(a) Remaining palatal fistula between the transferred tongue. (b) Z-plasty and pedicled flap from the transferred tongue flap are used to interdigitate two tissues. Note the conspicuous tongue papilla</p></caption><graphic xlink:href="AMS-5-174-g004"></graphic></fig></sec></sec><sec sec-type="results" id="sec1-3"><title>RESULTS</title><p>Demographic data of seven cleft patients with large alveolar/palatal fistulas, in which posteriorly based lateral tongue flap was used for soft-tissue reconstruction, are presented in <xref ref-type="table" rid="T1">Table 1</xref>. The age range of the patients was 14–45 years. The male-to-female ratio was 2/7. In three patients, this flap was used for closure of the large palatal fistula. In two patients, this flap was used for bilateral alveolar cleft repair simultaneous with bone grafting. The forked design was not used in these bilateral alveolar cleft patients, and only larger alveolar cleft was covered by tongue flap and smaller alveolar cleft was closed with the conventional buccal sliding flap. In one patient, it was used for reconstruction of premaxilla after the previous premaxilectomy, and in one edentulous patient for reconstruction of the unoperated unilateral wide complete cleft of the alveolar process and palate [<xref ref-type="fig" rid="F5">Figure 5</xref>].</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Data of cleft patients in which posteriorly based lateral tongue flap was used for reconstruction of alveolar/palatal fistula</p></caption><graphic xlink:href="AMS-5-174-g005"></graphic></table-wrap><fig id="F5" position="float"><label>Figure 5</label><caption><p>(a) Anteriorly located large palatal fistula closed by posteriorly based lateral tongue flap. (b) In bilateral alveolar cleft patient the oral-side coverage of the larger side was obtained by the tongue flap. (c) Premaxillectomy adult patient before surgery. (d) After 6 years of follow-up (without bone grafting). (e) In edentulous unilateral complete cleft of the alveolar process and palate</p></caption><graphic xlink:href="AMS-5-174-g006"></graphic></fig><p>The largest dimensions of fistula, closed by this flap was 5 cm × 1.5 cm. Treatment failure occurred only in one case, where this flap had been used for coverage of bone graft in an edentulous premaxilla. Speech quality did not improve dramatically after surgery (patient's self-assessment and parents’ opinion), and tongue shape at least 1 year after surgery remained to some degree asymmetric, in all the cases. The least changes were seen in the cases in which the proximal part of the flap was reinserted into the tongue in the second surgery for pedicle division [<xref ref-type="fig" rid="F6">Figure 6</xref>]. One patient needed revision surgery to reduce the bulk [<xref ref-type="fig" rid="F7">Figure 7</xref>], and residual fistula remained between the tongue flap and surrounding palatal tissues in two patients [<xref ref-type="fig" rid="F8">Figure 8</xref>].</p><fig id="F6" position="float"><label>Figure 6</label><caption><p>(a-c) Tongue shape remained asymmetrical after posteriorly based lateral tongue flap harvest. (d) Reinsertion of the pedicle into the donor site with Z-plasty techniques, diminish this deformity but cannot prevent it completely. (e) Postoperative photograph taken 3 months after operation</p></caption><graphic xlink:href="AMS-5-174-g007"></graphic></fig><fig id="F7" position="float"><label>Figure 7</label><caption><p>Adult patient with van der Woude syndrome needed a third surgery for tongue flap debulking</p></caption><graphic xlink:href="AMS-5-174-g008"></graphic></fig><fig id="F8" position="float"><label>Figure 8</label><caption><p>Residual fistula at the posterior border of the tongue flap</p></caption><graphic xlink:href="AMS-5-174-g009"></graphic></fig></sec><sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title><p>Posteriorly based lateral tongue flap is a good option for oral-side coverage of large oronasal fistulas.[<xref rid="ref11" ref-type="bibr">11</xref>] It does not limit the mobility of remaining tongue, and it is a good choice for reconstruction of central defects of the palate. Its location inside the dental arches and long pedicle prohibit application of maxilla-mandibular fixation to prevent spontaneous pedicle separation.[<xref rid="ref12" ref-type="bibr">12</xref>] Flap blood supply, in this variant of tongue flap is an axial pattern, depends on branches of the deep lingual artery.[<xref rid="ref13" ref-type="bibr">13</xref>] It provides sufficient mucosa for coverage of the oral-side in such fistulas. Patients with remaining large palatal fistulas have the nasal escape of air and nasal speech. Closure of fistula should improve speech theoretically.[<xref rid="ref14" ref-type="bibr">14</xref>] However in this study, the speech did not improve dramatically after the closure of the large fistula, which might be attributed to patients’ age and the establishment of speech habits. Therefore, closure of large palatal/alveolar fistulas in this age range (after 14 years or in adults) should be carried out with no promise to the patient about improvement in speech. More anterior location of fistulas in this series (hard palate and the alveolar process) was another contributing factor.</p><p>Anteriorly and posteriorly based tongue flaps have been used for reconstruction of palatal fistulas. The most common technique is anteriorly based, thin dorsal lingual flap [<xref ref-type="table" rid="T2">Table 2</xref>].[<xref rid="ref15" ref-type="bibr">15</xref><xref rid="ref16" ref-type="bibr">16</xref><xref rid="ref17" ref-type="bibr">17</xref><xref rid="ref18" ref-type="bibr">18</xref><xref rid="ref19" ref-type="bibr">19</xref><xref rid="ref20" ref-type="bibr">20</xref><xref rid="ref21" ref-type="bibr">21</xref><xref rid="ref22" ref-type="bibr">22</xref>] Anteriorly based tongue flaps are the most commonly used tongue flaps for closure of anteriorly located large palatal fistulas in cleft patients. The reasons include less tongue asymmetry and possibility to raise thin (3 mm) flaps.</p><table-wrap id="T2" position="float"><label>Table 2</label><caption><p>Reconstruction of the large palatal/alveolar fistulas in cleft patients, by tongue flaps in the literature</p></caption><graphic xlink:href="AMS-5-174-g010"></graphic></table-wrap><p>Few authors have used flaps from the lateral border of the tongue. The disadvantage of posteriorly based lateral tongue flap for closure of palatal fistula in anterior region is the thick nature of the flap, making it necessary to carry out a third surgery in some cases (in our series 16% of successful flaps) and leading to asymmetrical tongue shape. Reinsertion of maximal muscular bulk is strongly recommended to prevent a postoperative tongue deformity. Width limitation is the other restriction in this variant of tongue flap.</p><p>Posteriorly based lateral tongue flap has some advantages, including axial blood supply, not affecting the tongue mobility during the period of flap attachment to the palate and the most important factor, simplicity of the technique. We found bone suture technique to be a useful aid for suspending the tongue flap to the palate to prevent flap detachment in early postoperative period. Other ways suggested in the literature are anchoring the suture to the palatal mucosa (palatal sling), “parachuting and anchoring” the tongue to the nasal septum and “basket suspension” to support the tongue flap.[<xref rid="ref23" ref-type="bibr">23</xref><xref rid="ref24" ref-type="bibr">24</xref>] Suggested flaps other than tongue flap for closure of huge palatal fistulas in cleft patients are: Facial artery musculomucosal flap, posteriorly based buccinator myomucosal flap, superiorly based pharyngeal flap and finally temporal muscle, temporoparietal fascia, and free flaps.[<xref rid="ref25" ref-type="bibr">25</xref><xref rid="ref26" ref-type="bibr">26</xref><xref rid="ref27" ref-type="bibr">27</xref><xref rid="ref28" ref-type="bibr">28</xref><xref rid="ref29" ref-type="bibr">29</xref>]</p><p>It is a belief that the narrowed donor portion of the tongue enlarges with time because the muscle is usually well-exercised but in our series hypertrophy of the tongue muscles did not compensate the volume and long-term follow-up (upto 7 years) showed that the tongue never returns to its original size and remains to some degree asymmetric. This should be considered before surgery, explained to the patient and parents as well as written consent obtained.</p></sec><sec sec-type="conclusion" id="sec1-5"><title>CONCLUSION</title><p>Posteriorly based lateral tongue flap is an effective method to solve the problem of large palatal fistulas in adult cleft patients. The most useful indication for this flap is a large longitudinal palatal fistula, extending to the alveolar process. Asymmetrical tongue shape after surgery is the rule and speech improvement depends on patient's age and location of fistula.</p><sec id="sec2-4"><title>Financial support and sponsorship</title><p>Nil.</p></sec><sec id="sec2-5"><title>Conflicts of interest</title><p>There are no conflicts of interest.</p></sec></sec></body><back><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Murthy</surname><given-names>J</given-names></name></person-group><article-title>Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals</article-title><source>Indian J Plast Surg</source><year>2011</year><volume>44</volume><fpage>41</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">21713216</pub-id></element-citation></ref><ref id="ref2"><label>2</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bénateau</surname><given-names>H</given-names></name><name><surname>Traoré</surname><given-names>H</given-names></name><name><surname>Gilliot</surname><given-names>B</given-names></name><name><surname>Taupin</surname><given-names>A</given-names></name><name><surname>Ory</surname><given-names>L</given-names></name><name><surname>Guillou Jamard</surname><given-names>MR</given-names></name><etal></etal></person-group><article-title>Repair of palatal fistulae in cleft patients</article-title><source>Rev Stomatol Chir Maxillofac</source><year>2011</year><volume>112</volume><fpage>139</fpage><lpage>44</lpage><pub-id pub-id-type="pmid">21481901</pub-id></element-citation></ref><ref id="ref3"><label>3</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Charan Babu</surname><given-names>HS</given-names></name><name><surname>Bhagvandas Rai</surname><given-names>A</given-names></name><name><surname>Nair</surname><given-names>MA</given-names></name><name><surname>Meenakshi</surname></name></person-group><article-title>Single layer closure of palatal fistula using anteriorly based dorsal tongue flap</article-title><source>J Maxillofac Oral Surg</source><year>2009</year><volume>8</volume><fpage>199</fpage><lpage>200</lpage><pub-id pub-id-type="pmid">23139507</pub-id></element-citation></ref><ref id="ref4"><label>4</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Al-Qattan</surname><given-names>MM</given-names></name></person-group><article-title>A modified technique of using the tongue tip for closure of large anterior palatal fistula</article-title><source>Ann Plast Surg</source><year>2001</year><volume>47</volume><fpage>458</fpage><lpage>60</lpage><pub-id pub-id-type="pmid">11601587</pub-id></element-citation></ref><ref id="ref5"><label>5</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Posnick</surname><given-names>JC</given-names></name><name><surname>Getz</surname><given-names>SB</given-names><suffix>Jr</suffix></name></person-group><article-title>Surgical closure of end-stage palatal fistulas using anteriorly-based dorsal tongue flaps</article-title><source>J Oral Maxillofac Surg</source><year>1987</year><volume>45</volume><fpage>907</fpage><lpage>12</lpage><pub-id pub-id-type="pmid">3478437</pub-id></element-citation></ref><ref id="ref6"><label>6</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bütow</surname><given-names>KW</given-names></name><name><surname>Duvenage</surname><given-names>JG</given-names></name></person-group><article-title>Pedicled “flap” from a tongue flap</article-title><source>Int J Oral Maxillofac Surg</source><year>1986</year><volume>15</volume><fpage>581</fpage><lpage>4</lpage><pub-id pub-id-type="pmid">3097184</pub-id></element-citation></ref><ref id="ref7"><label>7</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ceran</surname><given-names>C</given-names></name><name><surname>Demirseren</surname><given-names>ME</given-names></name><name><surname>Sarici</surname><given-names>M</given-names></name><name><surname>Durgun</surname><given-names>M</given-names></name><name><surname>Tekin</surname><given-names>F</given-names></name></person-group><article-title>Tongue flap as a reconstructive option in intraoral defects</article-title><source>J Craniofac Surg</source><year>2013</year><volume>24</volume><fpage>972</fpage><lpage>4</lpage><pub-id pub-id-type="pmid">23714924</pub-id></element-citation></ref><ref id="ref8"><label>8</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kim</surname><given-names>YK</given-names></name><name><surname>Yeo</surname><given-names>HH</given-names></name><name><surname>Kim</surname><given-names>SG</given-names></name></person-group><article-title>Use of the tongue flap for intraoral reconstruction: A report of 16 cases</article-title><source>J Oral Maxillofac Surg</source><year>1998</year><volume>56</volume><fpage>716</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">9632329</pub-id></element-citation></ref><ref id="ref9"><label>9</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Buchbinder</surname><given-names>D</given-names></name><name><surname>St-Hilaire</surname><given-names>H</given-names></name></person-group><article-title>Tongue flaps in maxillofacial surgery</article-title><source>Oral Maxillofac Surg Clin North Am</source><year>2003</year><volume>15</volume><fpage>475</fpage><lpage>86</lpage><comment>v</comment><pub-id pub-id-type="pmid">18088698</pub-id></element-citation></ref><ref id="ref10"><label>10</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Johnson</surname><given-names>PA</given-names></name><name><surname>Banks</surname><given-names>P</given-names></name><name><surname>Brown</surname><given-names>AE</given-names></name></person-group><article-title>Use of the posteriorly based lateral tongue flap in the repair of palatal fistulae</article-title><source>Int J Oral Maxillofac Surg</source><year>1992</year><volume>21</volume><fpage>6</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">1569368</pub-id></element-citation></ref><ref id="ref11"><label>11</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kinnebrew</surname><given-names>MC</given-names></name><name><surname>Malloy</surname><given-names>RB</given-names></name></person-group><article-title>Posteriorly based, lateral lingual flaps for alveolar cleft bone graft coverage</article-title><source>J Oral Maxillofac Surg</source><year>1983</year><volume>41</volume><fpage>555</fpage><lpage>61</lpage><pub-id pub-id-type="pmid">6350546</pub-id></element-citation></ref><ref id="ref12"><label>12</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vaughan</surname><given-names>ED</given-names></name><name><surname>Brown</surname><given-names>AE</given-names></name></person-group><article-title>The versatility of the lateral tongue flap in the reconstruction of defects of the oral cavity</article-title><source>Br J Oral Surg</source><year>1983</year><volume>21</volume><fpage>1</fpage><lpage>10</lpage><pub-id pub-id-type="pmid">6573183</pub-id></element-citation></ref><ref id="ref13"><label>13</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Deshmukh</surname><given-names>A</given-names></name><name><surname>Kannan</surname><given-names>S</given-names></name><name><surname>Thakkar</surname><given-names>P</given-names></name><name><surname>Chaukar</surname><given-names>D</given-names></name><name><surname>Yadav</surname><given-names>P</given-names></name><name><surname>D’Cruz</surname><given-names>A</given-names></name></person-group><article-title>Tongue flap revisited</article-title><source>J Cancer Res Ther</source><year>2013</year><volume>9</volume><fpage>215</fpage><lpage>8</lpage><pub-id pub-id-type="pmid">23771361</pub-id></element-citation></ref><ref id="ref14"><label>14</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kummer</surname><given-names>AW</given-names></name><name><surname>Neale</surname><given-names>HW</given-names></name></person-group><article-title>Changes in articulation and resonance after tongue flap closure of palatal fistulas: Case reports</article-title><source>Cleft Palate J</source><year>1989</year><volume>26</volume><fpage>51</fpage><lpage>5</lpage><pub-id pub-id-type="pmid">2917418</pub-id></element-citation></ref><ref id="ref15"><label>15</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Guzel</surname><given-names>MZ</given-names></name><name><surname>Altintas</surname><given-names>F</given-names></name></person-group><article-title>Repair of large, anterior palatal fistulas using thin tongue flaps: Long-term follow-up of 10 patients</article-title><source>Ann Plast Surg</source><year>2000</year><volume>45</volume><fpage>109</fpage><lpage>14</lpage><pub-id pub-id-type="pmid">10949335</pub-id></element-citation></ref><ref id="ref16"><label>16</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Assunçao</surname><given-names>AG</given-names></name></person-group><article-title>The design of tongue flaps for the closure of palatal fistulas</article-title><source>Plast Reconstr Surg</source><year>1993</year><volume>91</volume><fpage>806</fpage><lpage>10</lpage><pub-id pub-id-type="pmid">8460182</pub-id></element-citation></ref><ref id="ref17"><label>17</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kim</surname><given-names>MJ</given-names></name><name><surname>Lee</surname><given-names>JH</given-names></name><name><surname>Choi</surname><given-names>JY</given-names></name><name><surname>Kang</surname><given-names>N</given-names></name><name><surname>Lee</surname><given-names>JH</given-names></name><name><surname>Choi</surname><given-names>WJ</given-names></name></person-group><article-title>Two-stage reconstruction of bilateral alveolar cleft using Y-shaped anterior-based tongue flap and iliac bone graft</article-title><source>Cleft Palate Craniofac J</source><year>2001</year><volume>38</volume><fpage>432</fpage><lpage>7</lpage><pub-id pub-id-type="pmid">11522164</pub-id></element-citation></ref><ref id="ref18"><label>18</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Barone</surname><given-names>CM</given-names></name><name><surname>Argamaso</surname><given-names>RV</given-names></name></person-group><article-title>Refinements of the tongue flap for closure of difficult palatal fistulas</article-title><source>J Craniofac Surg</source><year>1993</year><volume>4</volume><fpage>109</fpage><lpage>11</lpage><pub-id pub-id-type="pmid">8324083</pub-id></element-citation></ref><ref id="ref19"><label>19</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Coghlan</surname><given-names>K</given-names></name><name><surname>O’Regan</surname><given-names>B</given-names></name><name><surname>Carter</surname><given-names>J</given-names></name></person-group><article-title>Tongue flap repair of oro-nasal fistulae in cleft palate patients. A review of 20 patients</article-title><source>J Craniomaxillofac Surg</source><year>1989</year><volume>17</volume><fpage>255</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">2768480</pub-id></element-citation></ref><ref id="ref20"><label>20</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Pigott</surname><given-names>RW</given-names></name><name><surname>Rieger</surname><given-names>FW</given-names></name><name><surname>Moodie</surname><given-names>AF</given-names></name></person-group><article-title>Tongue flap repair of cleft palate fistulae</article-title><source>Br J Plast Surg</source><year>1984</year><volume>37</volume><fpage>285</fpage><lpage>93</lpage><pub-id pub-id-type="pmid">6743895</pub-id></element-citation></ref><ref id="ref21"><label>21</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Morel</surname><given-names>M</given-names></name><name><surname>Danino</surname><given-names>A</given-names></name><name><surname>Malka</surname><given-names>G</given-names></name></person-group><article-title>Use of the lateral tongue flap for closure of cleft palate. Retrospective study of seven cases</article-title><source>Ann Chir Plast Esthet</source><year>2001</year><volume>46</volume><fpage>5</fpage><lpage>9</lpage><pub-id pub-id-type="pmid">11233735</pub-id></element-citation></ref><ref id="ref22"><label>22</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Busic</surname><given-names>N</given-names></name><name><surname>Bagatin</surname><given-names>M</given-names></name><name><surname>Boric</surname><given-names>V</given-names></name></person-group><article-title>Tongue flaps in repair of large palatal defects</article-title><source>Int J Oral Maxillofac Surg</source><year>1989</year><volume>18</volume><fpage>291</fpage><lpage>3</lpage><pub-id pub-id-type="pmid">2509583</pub-id></element-citation></ref><ref id="ref23"><label>23</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Argamaso</surname><given-names>RV</given-names></name></person-group><article-title>The tongue flap: Placement and fixation for closure of postpalatoplasty fistulae</article-title><source>Cleft Palate J</source><year>1990</year><volume>27</volume><fpage>402</fpage><lpage>10</lpage><pub-id pub-id-type="pmid">2253388</pub-id></element-citation></ref><ref id="ref24"><label>24</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Elyassi</surname><given-names>AR</given-names></name><name><surname>Helling</surname><given-names>ER</given-names></name><name><surname>Closmann</surname><given-names>JJ</given-names></name></person-group><article-title>Closure of difficult palatal fistulas using a “parachuting and anchoring” technique with the tongue flap</article-title><source>Oral Surg Oral Med Oral Pathol Oral Radiol Endod</source><year>2011</year><volume>112</volume><fpage>711</fpage><lpage>4</lpage><pub-id pub-id-type="pmid">21439863</pub-id></element-citation></ref><ref id="ref25"><label>25</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lahiri</surname><given-names>A</given-names></name><name><surname>Richard</surname><given-names>B</given-names></name></person-group><article-title>Superiorly based facial artery musculomucosal flap for large anterior palatal fistulae in clefts</article-title><source>Cleft Palate Craniofac J</source><year>2007</year><volume>44</volume><fpage>523</fpage><lpage>7</lpage><pub-id pub-id-type="pmid">17760492</pub-id></element-citation></ref><ref id="ref26"><label>26</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nakakita</surname><given-names>N</given-names></name><name><surname>Maeda</surname><given-names>K</given-names></name><name><surname>Ando</surname><given-names>S</given-names></name><name><surname>Ojimi</surname><given-names>H</given-names></name><name><surname>Utsugi</surname><given-names>R</given-names></name></person-group><article-title>Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair</article-title><source>Br J Plast Surg</source><year>1990</year><volume>43</volume><fpage>452</fpage><lpage>6</lpage><pub-id pub-id-type="pmid">2393771</pub-id></element-citation></ref><ref id="ref27"><label>27</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Murthy</surname><given-names>J</given-names></name></person-group><article-title>Salvaging procedure for mutilated cleft palate by simultaneous tongue and pharyngeal flap surgery</article-title><source>Plast Reconstr Surg</source><year>2008</year><volume>122</volume><fpage>29e</fpage><lpage>30e</lpage><pub-id pub-id-type="pmid">18594364</pub-id></element-citation></ref><ref id="ref28"><label>28</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>van der Wal</surname><given-names>KG</given-names></name><name><surname>Mulder</surname><given-names>JW</given-names></name></person-group><article-title>The temporal muscle flap for closure of large palatal defects in CLP patients</article-title><source>Int J Oral Maxillofac Surg</source><year>1992</year><volume>21</volume><fpage>3</fpage><lpage>5</lpage><pub-id pub-id-type="pmid">1569362</pub-id></element-citation></ref><ref id="ref29"><label>29</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ninkovic</surname><given-names>M</given-names></name><name><surname>Hubli</surname><given-names>EH</given-names></name><name><surname>Schwabegger</surname><given-names>A</given-names></name><name><surname>Anderl</surname><given-names>H</given-names></name></person-group><article-title>Free flap closure of recurrent palatal fistula in the cleft lip and palate patient</article-title><source>J Craniofac Surg</source><year>1997</year><volume>8</volume><fpage>491</fpage><lpage>5</lpage><pub-id pub-id-type="pmid">9477835</pub-id></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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