Anteriorly-based Tongue Flap for Large Palatal Fistula

This video presents a case of a large hard palate fistula, which was repaired with an anterior tongue flap. The details of the procedure are described and demonstrated in detail, including both stages of the reconstruction, which were timed 3-4 weeks apart.

In cases of wide complete palatal clefts, excess tension on the anterior flaps used for palate repair can result in breakdown. Small, symptomatic fistulae between the mouth and the nasal cavity may be repaired with local flaps, however successful closure of larger defects requires transfer of robust, vascularized tissue. The dorsal tongue may serve as a relatively silent donor site for a large amounts of vascularized tissue, which may be utilized for delayed repair of relatively large anterior palatal defects.
This technique is indicated in cases of large anterior palatal fistulas, which may occur following failed primary or revision palatoplasty in which the quality and quantity of surrounding palatal tissue may not permit satisfactory closure of the palate.
Although no absolute contraindications exist, active tobacco use is a relative contraindication due to effects on wound healing. In addition patient cooperation and understanding is required in the postoperative period given tethering of the tongue that occurs following the first stage of the procedure. Therefore the surgery may no be appropriate for younger children or those with intellectual disabilities
The maximum area of harvest is based on the size of the fistula. The length of the flap from the midline should approximate the length of anterior to posterior dimensions of the fistula with at least 1 cm of excess to allow the turnover section to cover and to provide freedom for tongue mobility. The base of the flap should not exceed two-thirds of the width of the tongue, as to ensure adequate blood supply to the flap. The thickness of the anteriorly based myomucosal flap should be about 3 mm and deeper at its base to ensure sufficient blood supply.
Tongue flaps may be favorable over local mucoperiosteal flaps for anterior palatal fistulas when the defect is over 5 mm. Tongue flaps are favorable due to the central position in the floor of the mouth, and potential for mobility without compromising blood supply. Lingual myomucosal flaps are more robust than finer mucoperiosteal or buccinator myomucosal flaps. There is ample donor tissue within the anterior tongue, resulting in a near silent donor site. Disadvantages include difficulties with swallowing and articulation after the first stage of the procedure. This can persist to a lesser degree if the flap is overly bulky. A third stage may be required to debulk or demucosalize the flap if a tissue match is desired for palatal aesthetics.
Complications include bleeding, infection, flap necrosis, flap dehiscence, venous congestion following flap division, subtle changes in speech / articulation
On behalf of all authors, we declare no conflicts of interest.
Vasishta SM, Krishnan G, Rai YS, Desai A. The versatility of the tongue flap in the closure of palatal fistula. Craniomaxillofac Trauma Reconstr. 2012 Sep;5(3):145-60. https://www-ncbi-nlm-nih-gov.ezproxy.library.tufts.edu/pmc/articles/PMC3578650/ Mahajan RK, Chhajlani R, Ghildiyal HC. Role of tongue flap in palatal fistula repair: A series of 41 cases. Indian J Plast Surg. 2014 May;47(2):210-5. https://www-ncbi-nlm-nih-gov.ezproxy.library.tufts.edu/pmc/articles/PMC4147455/ Alsalman AK, Algadiem EA, Alwabari MS, Almugarrab FJ. Single-layer Closure with Tongue Flap for Palatal Fistula in Cleft Palate Patients. Plast Reconstr Surg Glob Open. 2016 Aug 24;4(8):e852. https://www-ncbi-nlm-nih-gov.ezproxy.library.tufts.edu/pmc/articles/PMC5010343/ Prakash A, Singh S, Solanki S, Doshi B, Kolla V, Vyas T, Jain A. Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair. Afr J Paediatr Surg. 2018 Apr-Jun;15(2):88-92. https://www-ncbi-nlm-nih-gov.ezproxy.library.tufts.edu/pmc/articles/PMC6615006/

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