Techniques to Improve Reliability and Predictability of the Dorsal Pedicled Tongue Flap in Closure of Palatal Defects and Oronasal Fistulae

Abstract

Introduction

Despite the improvement in surgical techniques in cleft palate surgery, oronasal fistulas continue to remain a challenge, usually the result of residual palatal and alveolar clefts and post-palatoplasty defects. The tongue flap is an extremely versatile, sturdy, reliable and efficient means of closure of anterior as well as posterior, unilateral and bilateral palatal defects, effectively functionally obliterating the oronasal communication, owing much of its success to its highly vascular structure, good mobility, texture match, central location and low donor site morbidity. However, it has a few drawbacks. Flap dehiscence and detachment during the early postoperative period is a troublesome complication owing to tongue movements during normal activities such as speaking, swallowing, yawning and coughing.

Aim

This article describes some of the methods which can be used to effectively alleviate these shortcomings.

Methods

A protocol of immobilizing the tongue by tethering it to the maxillary teeth for the 3-week postoperative period, and also maintaining the patient on nasogastric feeding, until the patient is taken up for surgical separation the pedicle, was employed in all patients in this case series.

Results

There was a successful and predictable take of the tongue flap at the donor site, namely the palatal/oronasal fistula with its successful closure, in all the patients.

Conclusion

Treatment of the oronasal fistula using a two-layer closure using the nasal mucoperiosteum together with an anteriorly based dorsal tongue flap is an easy and efficient method, whose reliability can be further increased by avoiding a common complication, namely tongue flap detachment in the postoperative period brought on by movements of the tongue, by immobilizing the tongue by tethering it to the maxillary teeth and also maintaining the patient on nasogastric feeding for the 3-week postoperative period.