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Closure of oro-antral fistula after partial maxillectomy using laterally based tongue flap: A case report
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 244–246
Contents lists available at SciVerse ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case report
Closure of oro-antral fistula after partial maxillectomy using laterally based tongue flap: A case report夽 Takamitsu Mano a,∗ , Yoshihide Mori b , Yoshiaki Kato a , Hiroyuki Nakano a , Yoshiya Ueyama a a b
Department of Oral and Maxillofacial Surgery, Yamaguchi University Graduate School of Medicine, Japan Department of Oral and Maxillofacial Surgery, Kyushu University Graduate School of Dentistry, Japan
a r t i c l e
i n f o
Article history: Received 28 January 2012 Received in revised form 6 May 2012 Accepted 23 May 2012 Available online 24 August 2012 Keywords: Tongue flap Oro-antral fistula Reconstruction
a b s t r a c t Use of a tongue flap has been advocated for the treatment of various defects in the mouth, and application for the closure of extended oro-nasal fistulae is widespread because of its rich blood supply. We report herein closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap. A 63-year-old man was diagnosed as upper gingival carcinoma. Partial maxillectomy was performed under general anesthesia. After the operation, maxillary defect was sealed with partial denture. About 5 years postoperatively, the patient complained of an unpleasant feeling of the partial denture. Closure operation was performed under general anesthesia. A tongue flap was raised from the dorsum of the tongue including mucosa and underlying muscle, based laterally. The tongue flap was turned upward and the tip was sutured to the lateral edge of the maxillary defect, then the base was sutured to the middle of the maxillary defect. The flap was well vascularized and necrosis of the flap did not occur. Five months postoperatively, the oro-antral fistula was kept completely closed. Therefore, closure of the oro-antral fistula using a tongue flap is useful for medium-sized maxillectomy defects. © 2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.
1. Introduction Local and regional flaps have been used for reconstruction after the resection of head and neck cancer. In recent years, the development of microvascular surgery and free tissue transfer has revolutionized reconstruction of the head and neck. However, this operation shows some disadvantages, such as an extremely long operation time and an extensive damage to the patient. Use of a tongue flap has been advocated for the treatment of various defects in the mouth, and application for the closure of extended oro-nasal fistulae is widespread because of its rich blood supply [1]. We report herein closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap. 2. Case report In July 2002, a 63-year-old man was referred to Yamaguchi University Hospital with delayed wound healing after removal of the
夽 AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi Ube, Yamaguchi 755-8505, Japan. Tel.: +81 836 22 2299; fax: +81 836 22 2298. E-mail address: [email protected] (T. Mano).
left upper second molar (Fig. 1). Pathological diagnosis of a biopsy specimen revealed squamous cell carcinoma. Partial maxillectomy was performed under general anesthesia after chemotherapy using continuous arterial infusion (Cisplatin, 127 mg; 5-FU, 4540 mg). Postoperatively, the oro-antral fistula was sealed with partial denture. The clinical course was uneventful and no recurrence or distant metastasis was observed. About 5 years postoperatively, the patient complained of an unpleasant feeling of the partial denture. The size of the oro-antral fistula was 24 mm × 18 mm. In May 2008, closure operation of the oro-antral fistula was performed using a local flap (palatal and buccal mucoperiosteal flap) and artificial dermis (Terudermis® , Olympus, Tokyo, Japan). However, oro-antral fistula gradually recurred (Fig. 2). In July 2009, re-operation was performed under general anesthesia. Palatal and buccal mucoperiosteal flaps were raised, turned inward, and sutured together to close the antral layer (Fig. 3). A tongue flap of approximately 30 mm × 30 mm was raised from the dorsum of the tongue including mucosa and approximately 4 mm of underlying muscle, based laterally (Figs. 4 and 5). The raw surface on the dorsum of the tongue was closed with 4-0 absorbable thread (Fig. 6). The tongue flap was turned upward and the tip was sutured to the lateral edge of the maxillary defect, then the base was sutured to the middle of the maxillary defect (Fig. 7). Tongue apex was fixed to upper incisors with 2-0 nylon threads to prevent undue tension on the flap pedicle. Intermaxillary fixation was not applied. Operation time was 1 h 33 min. Blood loss was minimal. Naso-gastric tube feeding was continued until the secondary procedure. Two weeks postoperatively,
2212-5558/$ – see front matter © 2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ajoms.2012.05.012
T. Mano et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 244–246
245
Fig. 4. Outline of the tongue flap. Fig. 1. Preoperative photograph showing a tumor mass of the left posterior gingiva (taken using a mirror).
Fig. 5. Raising the tongue flap.
Fig. 2. Preoperative photograph showing an oro-antral fistula (taken using a mirror).
the flap was cut off, trimmed and sutured under local anesthesia. Operation time was 20 min. The flap was well vascularized and necrosis of the flap did not occur. The shape of the tongue narrowed and a slight pronunciation disorder appeared. Five months postoperatively, the oro-antral fistula was kept completely closed and the pronunciation disorder resolved (Fig. 8A and B).
Fig. 6. Closure of the raw surface of the tongue dorsum.
3. Discussion
Fig. 3. The palatal and buccal mucous flaps were raised, turned inward, and sutured together to close the antral layer.
The maxilla plays a critical role in speech, swallowing, and mastication. Reconstruction of maxillectomy defects is thus one of the most difficult challenges faced by head and neck reconstructive surgeon. Maxillectomy defects are conventionally treated using a prosthetic obturator. In some clinics, defects are treated simultaneously using microvascular surgery. However, each technique has specific advantages and disadvantages [2]. The advantages of microvascular surgery are that the reconstruction is performed
246
T. Mano et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 244–246
Fig. 7. Suturing the tongue flap in place using multiple sutures.
obturators to close maxillectomy defects. However, in cases where use of prosthetic obturators is difficult, closure of the defect is necessary to avoid pronunciation disorders and dysphagia. When the maxillary defects have been reconstructed immediately or in a secondary procedure, a variety of local and regional flaps have been used with variable success [3–5]. Unfortunately, all these techniques have been limited by a paucity of available tissue, restricted reach of the vascular pedicle, and a frequent need for staged procedures to achieve optimal results [2]. Use of a buccal fat pad is a simple, convenient, and reliable method for reconstructing small to medium-sized oral defects [6]. However, in many cases the buccal fat pad has already been resected in the first operation, as in our patient. When flaps are used, defect size is an important factor. Although small fistula of the hard palate can often be repaired using local tissue, larger palatal fistula requires the transfer of non-palatal flaps to effect repair. The tongue flap with rich blood supply is a suitable and convenient source of such tissue [7]. Guerrero-Santos and Altamirano [8] first described the suitability of an anteriorly based dorsal tongue flap for repair of palatal fistulae in patients with cleft palate. In anterior defects of the hard palate, an anteriorly based flap is more appropriate, as mechanical factors preclude the use of a posteriorly based flap. In posterior defects of the hard palate, a posteriorly based flap is suitable. Cadenant et al. [9] pointed out that the rich submucosal plexus of the tongue permits random pattern flaps to be raised in virtually any direction, even across the midline. In this case, the oro-antral fistula was not small, so a tongue flap was chosen. The tongue flap of approximately 30 mm × 30 mm was raised from the dorsum of the tongue, based laterally. However, the blood supply to the tongue flap was good and no necrosis was observed. So, laterally based tongue flap is suitable and indicated to the medium-sized maxillary defect of lateral side. Closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap has three main disadvantages: (1) pronunciation disorder is likely to appear; (2) two operations are needed; and (3) speech and feeding are limited temporally. However, the advantages are: (1) reduced extensive damage; (2) short operation time; and (3) low risk of flap necrosis. Closure of the oroantral fistula using a tongue flap is thus useful for medium-sized maxillectomy defects. References
Fig. 8. Intra oral photographs at 5 months postoperatively. (A) The oro-antral fistula is completely closed and (B) the shape of the tongue is narrowed slightly.
as a single-stage procedure, obtaining good function of speech and swallowing, and the transfer of vascularized bone provides the option of dental restoration with osseointegrated implants. The disadvantages are the long operation time and the extensive damage to patient. Most of our patients therefore use prosthetic
[1] Bütow KW, Duvenage JG. Pedicled “flap” from a tongue flap. Int J Oral Maxillofac Surg 1986;15:581–4. [2] Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM. Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects. Head Neck 2010;32:860–8. [3] Kostrubala JG. Repair of extensive palatal defects with skin tubes. Plast Reconstr Surg 1950;5:512–5. [4] Bakamijian VY, Poole M. Maxillo-facial and palatal reconstructions with deltopectral flap. Br J Plast Surg 1977;30:17–37. [5] Colmenero C, Martorell V, Colmenero B, Sierra I. Temporalis myofacial flap for maxillofacial reconstruction. J Oral Maxillofac Surg 1991;49:1067–73. [6] Stajcic Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Craniomaxillofac Surg 1992;20:193–7. [7] Coghlan K, O’Regan B, Carter J. Tongue flap repair of oro-nasal fistulae in cleft palate patients—a review of 20 patients. J Craniomaxillofac Surg 1989;17: 255–9. [8] Guerrero-Santos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 1966;38:123–8. [9] Cadenant H, Combelles R, Fabie M. Lambeaux de langue, vascularisation, morphologie et utilisation. Ann Chir Plast 1973;18:223–5.
Contents lists available at SciVerse ScienceDirect
Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology journal homepage: www.elsevier.com/locate/jomsmp
Case report
Closure of oro-antral fistula after partial maxillectomy using laterally based tongue flap: A case report夽 Takamitsu Mano a,∗ , Yoshihide Mori b , Yoshiaki Kato a , Hiroyuki Nakano a , Yoshiya Ueyama a a b
Department of Oral and Maxillofacial Surgery, Yamaguchi University Graduate School of Medicine, Japan Department of Oral and Maxillofacial Surgery, Kyushu University Graduate School of Dentistry, Japan
a r t i c l e
i n f o
Article history: Received 28 January 2012 Received in revised form 6 May 2012 Accepted 23 May 2012 Available online 24 August 2012 Keywords: Tongue flap Oro-antral fistula Reconstruction
a b s t r a c t Use of a tongue flap has been advocated for the treatment of various defects in the mouth, and application for the closure of extended oro-nasal fistulae is widespread because of its rich blood supply. We report herein closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap. A 63-year-old man was diagnosed as upper gingival carcinoma. Partial maxillectomy was performed under general anesthesia. After the operation, maxillary defect was sealed with partial denture. About 5 years postoperatively, the patient complained of an unpleasant feeling of the partial denture. Closure operation was performed under general anesthesia. A tongue flap was raised from the dorsum of the tongue including mucosa and underlying muscle, based laterally. The tongue flap was turned upward and the tip was sutured to the lateral edge of the maxillary defect, then the base was sutured to the middle of the maxillary defect. The flap was well vascularized and necrosis of the flap did not occur. Five months postoperatively, the oro-antral fistula was kept completely closed. Therefore, closure of the oro-antral fistula using a tongue flap is useful for medium-sized maxillectomy defects. © 2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.
1. Introduction Local and regional flaps have been used for reconstruction after the resection of head and neck cancer. In recent years, the development of microvascular surgery and free tissue transfer has revolutionized reconstruction of the head and neck. However, this operation shows some disadvantages, such as an extremely long operation time and an extensive damage to the patient. Use of a tongue flap has been advocated for the treatment of various defects in the mouth, and application for the closure of extended oro-nasal fistulae is widespread because of its rich blood supply [1]. We report herein closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap. 2. Case report In July 2002, a 63-year-old man was referred to Yamaguchi University Hospital with delayed wound healing after removal of the
夽 AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants. ∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi Ube, Yamaguchi 755-8505, Japan. Tel.: +81 836 22 2299; fax: +81 836 22 2298. E-mail address: [email protected] (T. Mano).
left upper second molar (Fig. 1). Pathological diagnosis of a biopsy specimen revealed squamous cell carcinoma. Partial maxillectomy was performed under general anesthesia after chemotherapy using continuous arterial infusion (Cisplatin, 127 mg; 5-FU, 4540 mg). Postoperatively, the oro-antral fistula was sealed with partial denture. The clinical course was uneventful and no recurrence or distant metastasis was observed. About 5 years postoperatively, the patient complained of an unpleasant feeling of the partial denture. The size of the oro-antral fistula was 24 mm × 18 mm. In May 2008, closure operation of the oro-antral fistula was performed using a local flap (palatal and buccal mucoperiosteal flap) and artificial dermis (Terudermis® , Olympus, Tokyo, Japan). However, oro-antral fistula gradually recurred (Fig. 2). In July 2009, re-operation was performed under general anesthesia. Palatal and buccal mucoperiosteal flaps were raised, turned inward, and sutured together to close the antral layer (Fig. 3). A tongue flap of approximately 30 mm × 30 mm was raised from the dorsum of the tongue including mucosa and approximately 4 mm of underlying muscle, based laterally (Figs. 4 and 5). The raw surface on the dorsum of the tongue was closed with 4-0 absorbable thread (Fig. 6). The tongue flap was turned upward and the tip was sutured to the lateral edge of the maxillary defect, then the base was sutured to the middle of the maxillary defect (Fig. 7). Tongue apex was fixed to upper incisors with 2-0 nylon threads to prevent undue tension on the flap pedicle. Intermaxillary fixation was not applied. Operation time was 1 h 33 min. Blood loss was minimal. Naso-gastric tube feeding was continued until the secondary procedure. Two weeks postoperatively,
2212-5558/$ – see front matter © 2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ajoms.2012.05.012
T. Mano et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 244–246
245
Fig. 4. Outline of the tongue flap. Fig. 1. Preoperative photograph showing a tumor mass of the left posterior gingiva (taken using a mirror).
Fig. 5. Raising the tongue flap.
Fig. 2. Preoperative photograph showing an oro-antral fistula (taken using a mirror).
the flap was cut off, trimmed and sutured under local anesthesia. Operation time was 20 min. The flap was well vascularized and necrosis of the flap did not occur. The shape of the tongue narrowed and a slight pronunciation disorder appeared. Five months postoperatively, the oro-antral fistula was kept completely closed and the pronunciation disorder resolved (Fig. 8A and B).
Fig. 6. Closure of the raw surface of the tongue dorsum.
3. Discussion
Fig. 3. The palatal and buccal mucous flaps were raised, turned inward, and sutured together to close the antral layer.
The maxilla plays a critical role in speech, swallowing, and mastication. Reconstruction of maxillectomy defects is thus one of the most difficult challenges faced by head and neck reconstructive surgeon. Maxillectomy defects are conventionally treated using a prosthetic obturator. In some clinics, defects are treated simultaneously using microvascular surgery. However, each technique has specific advantages and disadvantages [2]. The advantages of microvascular surgery are that the reconstruction is performed
246
T. Mano et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 244–246
Fig. 7. Suturing the tongue flap in place using multiple sutures.
obturators to close maxillectomy defects. However, in cases where use of prosthetic obturators is difficult, closure of the defect is necessary to avoid pronunciation disorders and dysphagia. When the maxillary defects have been reconstructed immediately or in a secondary procedure, a variety of local and regional flaps have been used with variable success [3–5]. Unfortunately, all these techniques have been limited by a paucity of available tissue, restricted reach of the vascular pedicle, and a frequent need for staged procedures to achieve optimal results [2]. Use of a buccal fat pad is a simple, convenient, and reliable method for reconstructing small to medium-sized oral defects [6]. However, in many cases the buccal fat pad has already been resected in the first operation, as in our patient. When flaps are used, defect size is an important factor. Although small fistula of the hard palate can often be repaired using local tissue, larger palatal fistula requires the transfer of non-palatal flaps to effect repair. The tongue flap with rich blood supply is a suitable and convenient source of such tissue [7]. Guerrero-Santos and Altamirano [8] first described the suitability of an anteriorly based dorsal tongue flap for repair of palatal fistulae in patients with cleft palate. In anterior defects of the hard palate, an anteriorly based flap is more appropriate, as mechanical factors preclude the use of a posteriorly based flap. In posterior defects of the hard palate, a posteriorly based flap is suitable. Cadenant et al. [9] pointed out that the rich submucosal plexus of the tongue permits random pattern flaps to be raised in virtually any direction, even across the midline. In this case, the oro-antral fistula was not small, so a tongue flap was chosen. The tongue flap of approximately 30 mm × 30 mm was raised from the dorsum of the tongue, based laterally. However, the blood supply to the tongue flap was good and no necrosis was observed. So, laterally based tongue flap is suitable and indicated to the medium-sized maxillary defect of lateral side. Closure of an oro-antral fistula after partial maxillectomy using a laterally based tongue flap has three main disadvantages: (1) pronunciation disorder is likely to appear; (2) two operations are needed; and (3) speech and feeding are limited temporally. However, the advantages are: (1) reduced extensive damage; (2) short operation time; and (3) low risk of flap necrosis. Closure of the oroantral fistula using a tongue flap is thus useful for medium-sized maxillectomy defects. References
Fig. 8. Intra oral photographs at 5 months postoperatively. (A) The oro-antral fistula is completely closed and (B) the shape of the tongue is narrowed slightly.
as a single-stage procedure, obtaining good function of speech and swallowing, and the transfer of vascularized bone provides the option of dental restoration with osseointegrated implants. The disadvantages are the long operation time and the extensive damage to patient. Most of our patients therefore use prosthetic
[1] Bütow KW, Duvenage JG. Pedicled “flap” from a tongue flap. Int J Oral Maxillofac Surg 1986;15:581–4. [2] Moreno MA, Skoracki RJ, Hanna EY, Hanasono MM. Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects. Head Neck 2010;32:860–8. [3] Kostrubala JG. Repair of extensive palatal defects with skin tubes. Plast Reconstr Surg 1950;5:512–5. [4] Bakamijian VY, Poole M. Maxillo-facial and palatal reconstructions with deltopectral flap. Br J Plast Surg 1977;30:17–37. [5] Colmenero C, Martorell V, Colmenero B, Sierra I. Temporalis myofacial flap for maxillofacial reconstruction. J Oral Maxillofac Surg 1991;49:1067–73. [6] Stajcic Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Craniomaxillofac Surg 1992;20:193–7. [7] Coghlan K, O’Regan B, Carter J. Tongue flap repair of oro-nasal fistulae in cleft palate patients—a review of 20 patients. J Craniomaxillofac Surg 1989;17: 255–9. [8] Guerrero-Santos J, Altamirano JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 1966;38:123–8. [9] Cadenant H, Combelles R, Fabie M. Lambeaux de langue, vascularisation, morphologie et utilisation. Ann Chir Plast 1973;18:223–5.