Vol. 112 No.

6 December 2011

ORAL AND MAXILLOFACIAL SURGERY Editor: David S. Precious

Closure of difficult palatal fistulas using a parachuting and

anchoring technique with the tongue flap
Ali R. Elyassi, DDS,a Eric R. Helling, MD,b and James J. Closmann, DDS,c Honolulu, HI
TRIPLER ARMY MEDICAL CENTER

The tongue flap has been described in reconstructing palatal defects. Nevertheless, properly securing the flap
to the palatal defect has continued to pose a challenge, especially because the flap becomes mobile with normal
activities (i.e., speech and swallow). For this reason, alternative fixation schemes have been discussed in literature, but
do not always solve the problem. In this article, we offer an alternative method for positioning and securing the tongue
flap into the palatal defect. The authors of this article believe that advantages of this technique include an increase in
flap security and immobility and a decrease in postoperative maxillomandibular fixation requirement. Although
unanswered questions still remain regarding improved flap retention with this method, we believe that the
parachuting and anchoring technique provides an alternative method that can most definitely add to the surgeons
armamentarium. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:711-714)

Because of its rich blood supply and pliability, the
tongue flap has become a versatile option for recon-
structing the lip, cheek, oroanatral fistula, or palate.1,2
Moreover, the tongue flap can be successfully used for
closure of difficult-to-close palatal fistulas, including
very large palatal fistulas or in severely scarred palates
from prior surgery.3,4 Tongue flaps can be created from
the ventral, dorsal, or lateral parts of the tongue.5 Nu-
merous studies have shown the successful use of both
anteriorly based and posteriorly based flaps for the
closure of palatal fistulas.6-8 Nevertheless, properly se-
curing the flap to the palatal defect has continued to
pose a challenge, especially because the flap becomes
mobile with normal activities (i.e., speech and swal-
low). For this reason, fixation schemes, such as trans-
fixing the lingual base with Kirschner wires (K-wires)
or intermaxillary fixation have been previously pro-
a
Chief Resident, Department of Oral & Maxillofacial Surgery, Tripler
Army Medical Center.
b
Chief, Department of Plastic Surgery, Tripler Army Medical Center.
c
Chief, Department of Oral & Maxillofacial Surgery, Tripler Army
Medical Center.
Received for publication Jul 12, 2010; returned for revision Nov 16,
2010; accepted for publication Dec 26, 2010.
1079-2104/$ - see front matter
Published by Mosby, Inc.
doi:10.1016/j.tripleo.2010.12.022
posed, but do not always solve the problem.9 In this
article, we offer an alternative method for positioning
and securing the tongue flap into the palatal defect.
TECHNIQUE
Once the proposed flap has been designed and
marked, local anesthetic with epinephrine is injected
into the proposed surgical site. For cosmetic, func-
tional, and vitality reasons, the tip of the tongue should
not be included in the flap design. Silk sutures (2-0) are
placed on both sides of the tongue to pull the tongue
forward into view and provide optimal access. The flap
is designed to use nearly the full length of the tongue to
minimize tension on the flap. The width is designed so
that it is wider than the defect to be closed. Either the
paramedian (in adults) or median (in children) portion
of the tongue is elevated, and the flap is based anteri-
orly or posteriorly, depending on the location of the
defect.
Electrocautery, a surgical blade, or carbon dioxide
(CO2) laser is then used to make the initial incision on
the tongue (Fig. 1). The myomucosal flap is elevated
anterior to the circumvallate papilla to maximize flap
survival (Fig. 2).8 The donor bed within the tongue is
closed primarily with a running 3-0 Vicryl suture to
eliminate dead space and aid in hemostasis (Fig. 3).
Care should be exercised to avoid strangulation of the

711

712 Elyassi et al.
Fig. 1. Surgical site marked on the dorsal surface of the
tongue. Electrocautery is used to elevate a median tongue
flap.
Fig. 2. Median tongue flap elevated.
flap during closure. An 11 blade is then used to cir-
cumferentially de-epithelialize the donor site (dorsum
of tongue) and the mucosa of the recipient site (fistula).
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December 2011
Fig. 3. Tongue flap with donor site closed and flap de-
epithelialized, ready to be secured to catheter and inset into
defect.
With this step, only a very thin layer of the outer
mucosa is removed until bleeding tissue is reached. The
authors of this article prefer to use a surgical blade and
not electrocautery or CO2 laser, which would cause
thermal injury to the surrounding tissue and compro-
mise vascularity, and, thus, wound healing.10
Vicryl sutures (4-0) are then placed in the de-epithe-
lialized tissue surrounding the palatal defect and in the
respective de-epithelialized tongue flap tissue. These
sutures are placed in a horizontal mattress fashion and
left untied. They can be left on hemostats to keep them
organized. The sutures should be placed in such a
manner to allow adequate tongue flap tissue to pass
through the palatal defect and reach the nasal septum in
a tension-free manner. A French 35.6-cm red rubber
utility catheter is passed through the nose and fistula
and into the oral cavity. The distal end of the catheter is
then secured to the distal end of the tongue flap using 2
or 3 3-0 Vicryl sutures placed in an interrupted fashion.
Once all sutures are in proper position, the catheter is
pulled back through the nose allowing the tongue flap
to parachute into the palatal defect (Fig. 4). While
pulling the catheter and holding the tongue flap in its
desired position, another surgeon or assistant ties off
the 4-0 Vicryl sutures connecting the palatal defect to
the tongue flap. The distal end of the tongue is then
anchored to the nasal septum using 2 or 3 4-0 Vicryl
sutures, before completing the procedure (Fig. 5). The
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Volume 112, Number 6
Fig. 4. Catheter, while secured to tongue flap, is pulled
through nose parachuting the flap and previously passed
sutures into the palatal defect.
Fig. 5. The tongue flap is secured to the nasal septum with
Vicryl sutures, anchoring the flap for extra stability.
goal is to obtain tension-free and watertight closure
of the palatal defect. Added security is achieved by
the additional sutures placed into the nasal septum.
Elyassi et al. 713
Once proper closure of the palatal defect is per-
formed, the sutures connecting the catheter to the
tongue flap are cut and the catheter can be removed.
The decision is then made as to whether or not to
place the patient in intermaxillary fixation. In our
experience, using this parachuting and anchoring
technique, fixation is not always necessary, and ei-
ther a Jaw Bra or Bartons bandage can suffice.5
Once the patient is extubated, he or she should be
admitted overnight for airway monitoring. Patients are
kept on a liquid diet with limitation of mouth opening
achieved using a Jaw Bra or Bartons bandage, if
intermaxillary fixation is not used.5 Limitation in
speaking is also encouraged to avoid undue tension on
the pedicle. The tongue flap is allowed to heal for 3
weeks before the patient is then taken back to the
operating room to divide the flap and close the donor
site.
DISCUSSION
The buccal flap, palatal flap, buccal fat pad, and
tongue flap have all been described as autogenous soft
tissue flaps for closure of oroantral fistulas.11-13 Tongue
flaps are suitable for reconstruction of the lip, cheek,
and palatal or oroantral fistulas.1,2 Tongue flaps can be
created from the ventral, dorsal, or lateral portion of the
tongue.5 Anteriorly based and posteriorly based tongue
flaps have been presented in literature for closure of
palatal fistulas.6-8 some argue that the anteriorly based
flap is better tolerated by most patients and allows for
the greatest degree of tongue mobility, decreasing risk
of tearing the flap from its palatal insertion.11
When using the tongue flap to close a palatal defect,
at least 2 stages are required. The first stage involves
flap design and placement into the defect. The flap is
then left in place for 14 to 21 days to allow for adequate
healing. Next, the pedicle is severed, tongue tissue is
reinset, and excess tissue is removed. In some cases, a
third-stage procedure may be necessary to debulk the
recipient site and improve esthetics, but this should not
be performed before 3 months after separation of the
pedicle.12
The success of the tongue flap is largely attributable
to its favorable vasculature. The lingual artery and its
branches are mainly responsible for the rich vascular
supply to the tongue. The dorsal tongue flap has a
random vascular pattern, but posteriorly based lateral
flap design appears to have an axial-like pattern, con-
taining the deep lingual artery.7,12,14 When using the
random pattern myomucosal tongue flap, the flap
should be thick enough (3-10 mm) to include adequate
muscle mass.8,12 The base of the flap should be broad
enough to prevent vascular compromise and to permit
tension-free mobility of the tongue.7 Some even argue

714 Elyassi et al.
against using local anesthetic with vasoconstrictor be-
cause it can potentially cause ischemic damage.7
De-epithelialization of the donor and recipient sites
is an important step to ensure proper healing and im-
prove success rate. It is these raw surfaces that con-
tribute to the leak of plasma and proteins into the
wound. In addition, flap design and mobility also play
an important role in flap success. It is prudent to secure
the tongue flap to the defect in a tension-free and
watertight manner. In our cases, we used a French
35.6-cm red rubber utility catheter to help parachute
or inset the tongue flap into the palatal defect. Further-
more, we anchored the distal portion of the tongue
flap to the nasal mucosa using 4-0 Vicryl sutures placed
in an interrupted fashion. We believe the sutures to the
nasal mucosa give added security and immobility of the
tongue flap.
Potential complications from this procedure are sim-
ilar to those from performing any tongue flap procedure
and may include flap failure, bleeding, swelling, pain,
infection, hematoma, contour deformities, temporary
loss of tongue sensation, gustatory changes, require-
ment for a 2-stage or 3-stage procedure, and, in rare
cases, partial or total necrosis of flap.5,6,12 The authors
of this article believe that advantages of this technique
include an increase in flap security and immobility, and
a decrease in postoperative intermaxillary fixation re-
quirement. Although unanswered questions still remain
regarding improved flap retention with this method, we
believe that the parachuting and anchoring technique
provides an alternative method that can most definitely
add to the surgeons armamentarium.
Special thanks to Juan D. Nava, who created the spec-
tacular illustrations for this manuscript.
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Surg 1988;17:110.
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Maxillofac Surg 1992;21:6.
Reprint requests:
Ali R. Elyassi, DDS
Chief Resident
Department of Oral & Maxillofacial Surgery
Tripler Army Medical Center
3075 Ala Poha Place, Suite 2112
Honolulu, HI 96818
aelyassi@gmail.com