Anteriorly-based Tongue Flap for Large Palatal Fistula

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

Nasotracheal or lateral oral RAE endotracheal tube
Dingman mouth gag
Plastic cheek retractor
Marking pen
Cottonoids
Oxymetazoline
Lidocaine/Epinephrine
Needle tip cautery
15 blade
Soft tissue elevators (Cottle, Woodson, Freer)
Tenotomy and suture scissors
Fine toothed forceps (Geralds)
Needle driver
Polyglactin (vicryl) sutures

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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.

Complications include bleeding, infection, flap necrosis, flap dehiscence, venous congestion following flap division, subtle changes in speech / articulation

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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://pubmed.ncbi.nlm.nih.gov/23997859/
Mahajan RK, Chhajlani R, Ghildiyal HC. Role of tongue flap in palatal fistula repair: A series of 41 cases. Indian J Plast Surg. 2014;47:210–5. https://europepmc.org/articles/PMC4147455