Wednesday, October 13, 2004 - 7:46 AM
6208

Oral Commisure Reconstruction Using Bilateral Distally Based Ventral Tongue Flaps

David Singer, MD and Richard J Zienowicz, MD.

Purpose: The oral commisure is a dynamic, three dimensional structure that provides important definition to facial expression. Traumatic injury of this area frequently leads to glaring asymmetry due to loss of this delicate lip anatomy. The magnitude of injury to this area varies considerably and most surgical techniques that have been used for this anomaly borrow soft tissues from contiguous areas further diminishing the normal soft tissue complement. Donelan (1995) described an anteriorly-based ventral tongue flap that brought tissue with excellent color match in sufficient quantity to provide a far better solution for this difficult problem. Extrapolating this resourceful technique by the application of bilateral tongue flaps effectively doubles soft tissue recruitment enabling the surgeon to aggressively release the contracture and more reliably restore the structural anatomy. Use of bilateral ventral tongue flaps has not been previously described. Methods/Techniques: Three patients are presented with post-traumatic injuries to the oral commisure, including electrical burns as well as dog bites. The patients underwent post-injury therapy that included wound massage and splinting devices. After wound remodeling and maturation, the reconstruction was performed. Oral commisurotomy was performed recreating the defect to match the contralateral oral commisure-cupid’s bow relationship. Bilateral distally based ventral tongue flaps were raised at the submucosal level, using the defect size to dictate length of flap as well as width. The ispilateral tongue flap was inset into the upper lip-commisure, whereas the contralateral tongue flap was inset into the lower lip-commisure. This created a sandwich of bilateral tongue flaps that allowed definition of the oral commisure angle without blunting. A tongue-labial sulcus stitch maintained the tongue in ideal position. Subsequently, the tongue flaps were divided at two weeks, inset was performed, with closure of the donor site. Results: All ventral tongue flaps survived without necrosis. Further there were no donor site complications including speech, tongue movement, or pain. One patient bit through the contralaterally based tongue flap two weeks following surgery and serendipitously left precisely the intended amount of healed tissue at the inferior commissure. While one patient has undergone revision for debulking of the flap, the other two patients have not required surgical intervention. Conservatively, steroid can be injected to promote debulking of the flaps if necessary. Conclusion: Generally, the subtle relationship of the upper lip to the lower lip as well as oral commisure angle can be effectively recreated with this technique. The color match to adjacent mucosa is excellent and nearly imperceptible once healing has occurred. The functional improvements have been profound in regards to speech, eating, and facial animation. Further, the donor site is extremely forgiving and no compromise of speech has been identified by patient, family or physician. Video documentation of marked improvement in balanced facial expression will be presented.