J Oral Maxillofac
Surg
49:756-757.1990
A New Tongue Reduction HENRY V. KRUCHINSKY,
Tongue enlargement can be either a congenital or acquired condition. The former is commonly associated with certain syndromes such as Down syndrome, hypertelorism, and congenital hyperthyroidism (cretinism). ‘J Acquired macroglossia can develop from tumor growth within the muscle or be associated with a jaw deformity such as mandibular prognathism.3 Vogel et al4 have developed a clinical classification for defining congenital and acquired forms of macroglossia. Several techniques of tongue reduction have been reported. These methods are fully described in a monograph by Reichenbach et al.’ In such cases Rheinwald3 suggests a wedge-shaped resection of the tongue tip, 3 to 5 cm in width (Fig IA). Meig’s technique includes the lateral aspect of the tongue in the resection.6 However, these two methods have a mutual disadvantage: they provide a reduced length but not a reduced width. Pichler and Trauner’ recommended tongue reduction at two sites: in the area of the back and the tip (Fig 1B). However, retaining tissue between the areas of resection often leads to inadequate correction of the problem. That is why Egyedi and Obwegeser,8 and later Reichenbach et aL5 modified the procedure to include a block excision of the tip and the middle part of the tongue (Fig 1, C and D).
American
Association
of Oral
and Maxillofacial
PROF, MD*
These methods have very much in common and are an efftcient way to provide longitudinal as well as transverse tongue reduction. All the aforementioned techniques have the same mutual shortcoming: after such an operation the patient is devoid of the tip of the tongue, which is the most mobile and sensitive part. Moreover, healing of the middle of the wound at the border of the two muscle masses is often unfavorable. These shortcomings gave use to a new technique that has been developed in our department. This procedure enables the tip of the tongue to be maintained and the suture line to be shifted from the midline. Technical Details Surgery is performed under general anesthesia administered by way of a nasotracheal tube. The tongue is drawn forward and fixed in this position with two ligatures passed through all the layers of the lateral areas of the tongue. This step ensures reliable tongue fixation during surgery, as well as control of bleeding by application of ligature pressure on the tongue tissues. The tongue sites chosen for excision are marked. A wedge-shaped strip is marked along the middle of the tongue, widening to the front (1.5 to 2.0 cm in width), and the lateral area to be excised is outlined on the tip of the tongue (0.6 to 0.7 cm in width) (Fig 2A). The surgeon can decide which half of the tip should be removed. The surgery is performed with a conventional scalpel. The wedge-shaped area of the middle of the tongue is excised first, starting from the top of the mucous membrane and penetrating into the depth of the muscle mass, including
* Supervisor, Department of Stomatology and Facial Plastic Surgery, Minsk, USSR. Address correspondence and reprint requests to Dr Kruchinsky: 93 Leninski Ave, Apt 3. 220012, City of Minsk, Buelorussian USSR. 0 1990 geons
Method
Sur-
0278-2391/90/4807-0019$3.00/O
FIGURE 1. Tongue reduction techniques described in monographs by Reichenbach et aI5 and Bernadsky? A, According to Rheinwald.’ B, According to Pichler.’ C, According to Egyedi and Obwegeser.* D, According to Reichenbach et al5
756
757
HENRY V. KRUCHINSKY
B FIGURE 2. Tongue reduction technique. A, The site in the back and tip of the tongue chosen for excision. Visible is a preserved strip of the tongue tip connected with the lateral surface. Hatched area is the tongue site to be excised. B, Tongue condition after resection has been performed and surgical site sutured.
practically all the muscle layers. To control hemorrhage the surgical assistant periodically presses the carotid arteries against the cervical vertebra with the fingers. Following excision of the tissue the wounds are closed quickly in layers (Fig 2B). The described surgical procedure results in significant longitudinal and transversal tongue reduction, while at the same time maintaining integrity of the tongue tip. Report of a Case A Syear-old girl was admitted to the Buelorussian Institute for Advanced Medical Training in 1988. The diagnoses at admission were Beckwith-Widemann syndrome and mandibular prognathism with widened interdental spacing of the anterior primary teeth. The girl previously had been referred to the Institute for Genetics where the diagnosis was made and she was referred to our hospital for further treatment. Physical examination revealed only two features of the syndrome: macroglossia and hyper-
trophy of the clitoris. Examination of her mother resulted in the same diagnosis, but her older sister did not have the syndrome. The tongue reduction surgery was performed in April 1988 according to the aforementioned technique. The postoperative course included tongue edema and lymphostasis, which gradually normalized. The tongue swelling diminished with time so that the tongue was confined within the oral cavity and regained its mobility. The patient’s condition before and 2 weeks and 6 months after surgery is shown in Fig 3. The surgery resulted in sufficient tongue reduction. Afterward, the patient was referred to an orthodontist who provided further treatment to correct the deformed mandible. The girl was examined 6 months after surgery and the tongue had almost regained its normal size. The tip of the tongue was somewhat longer as compared with normal, but moved easily. The girl was able to close her mouth with ease, applying no tension to her lips.
The aforementioned method of tongue reduction has been successfully used in two more teenagers with secondary macroglossia that developed from mandibular prognathism. References 1. Lazyuk GI: Teratology of a Man. Moscow. Medicine, 1979, P 98 2. Thoma KH: Oral Surgery, ~012. Saint Louis, MO, Mosby, 1969, p 122 3. Reinwald U: Die Operative Zungenverkleinerung aus Zahnartlicher Indikation. Dtsch Mund Kieferheilk 27:129, 1957 4. Vogel J, Milliken J, Kaban L: Macroglossia: A review of the condition and a new classification. Plast Reconstr Surg 78:715, 1986 5. Reichenbach E, Kale H, Briicl H: Chirurgische Kieferorthopidie. Leipzig, 1%5, pp 85-86 6. Bemadsky Yu I: Traumatology and Reconstructive Maxillofacial Surgery. Kiev, Higher School, 1985, p 352 7. Pichler H, Trauner R: Mund und Kieferchirurgie. Wien, 1948 8. Egyedi P, Obwegeser H: Zur Operativen Zungen Verkeinerung. Dtsch Zahn Mund Kiefer 41:16, 1964
Surg
49:756-757.1990
A New Tongue Reduction HENRY V. KRUCHINSKY,
Tongue enlargement can be either a congenital or acquired condition. The former is commonly associated with certain syndromes such as Down syndrome, hypertelorism, and congenital hyperthyroidism (cretinism). ‘J Acquired macroglossia can develop from tumor growth within the muscle or be associated with a jaw deformity such as mandibular prognathism.3 Vogel et al4 have developed a clinical classification for defining congenital and acquired forms of macroglossia. Several techniques of tongue reduction have been reported. These methods are fully described in a monograph by Reichenbach et al.’ In such cases Rheinwald3 suggests a wedge-shaped resection of the tongue tip, 3 to 5 cm in width (Fig IA). Meig’s technique includes the lateral aspect of the tongue in the resection.6 However, these two methods have a mutual disadvantage: they provide a reduced length but not a reduced width. Pichler and Trauner’ recommended tongue reduction at two sites: in the area of the back and the tip (Fig 1B). However, retaining tissue between the areas of resection often leads to inadequate correction of the problem. That is why Egyedi and Obwegeser,8 and later Reichenbach et aL5 modified the procedure to include a block excision of the tip and the middle part of the tongue (Fig 1, C and D).
American
Association
of Oral
and Maxillofacial
PROF, MD*
These methods have very much in common and are an efftcient way to provide longitudinal as well as transverse tongue reduction. All the aforementioned techniques have the same mutual shortcoming: after such an operation the patient is devoid of the tip of the tongue, which is the most mobile and sensitive part. Moreover, healing of the middle of the wound at the border of the two muscle masses is often unfavorable. These shortcomings gave use to a new technique that has been developed in our department. This procedure enables the tip of the tongue to be maintained and the suture line to be shifted from the midline. Technical Details Surgery is performed under general anesthesia administered by way of a nasotracheal tube. The tongue is drawn forward and fixed in this position with two ligatures passed through all the layers of the lateral areas of the tongue. This step ensures reliable tongue fixation during surgery, as well as control of bleeding by application of ligature pressure on the tongue tissues. The tongue sites chosen for excision are marked. A wedge-shaped strip is marked along the middle of the tongue, widening to the front (1.5 to 2.0 cm in width), and the lateral area to be excised is outlined on the tip of the tongue (0.6 to 0.7 cm in width) (Fig 2A). The surgeon can decide which half of the tip should be removed. The surgery is performed with a conventional scalpel. The wedge-shaped area of the middle of the tongue is excised first, starting from the top of the mucous membrane and penetrating into the depth of the muscle mass, including
* Supervisor, Department of Stomatology and Facial Plastic Surgery, Minsk, USSR. Address correspondence and reprint requests to Dr Kruchinsky: 93 Leninski Ave, Apt 3. 220012, City of Minsk, Buelorussian USSR. 0 1990 geons
Method
Sur-
0278-2391/90/4807-0019$3.00/O
FIGURE 1. Tongue reduction techniques described in monographs by Reichenbach et aI5 and Bernadsky? A, According to Rheinwald.’ B, According to Pichler.’ C, According to Egyedi and Obwegeser.* D, According to Reichenbach et al5
756
757
HENRY V. KRUCHINSKY
B FIGURE 2. Tongue reduction technique. A, The site in the back and tip of the tongue chosen for excision. Visible is a preserved strip of the tongue tip connected with the lateral surface. Hatched area is the tongue site to be excised. B, Tongue condition after resection has been performed and surgical site sutured.
practically all the muscle layers. To control hemorrhage the surgical assistant periodically presses the carotid arteries against the cervical vertebra with the fingers. Following excision of the tissue the wounds are closed quickly in layers (Fig 2B). The described surgical procedure results in significant longitudinal and transversal tongue reduction, while at the same time maintaining integrity of the tongue tip. Report of a Case A Syear-old girl was admitted to the Buelorussian Institute for Advanced Medical Training in 1988. The diagnoses at admission were Beckwith-Widemann syndrome and mandibular prognathism with widened interdental spacing of the anterior primary teeth. The girl previously had been referred to the Institute for Genetics where the diagnosis was made and she was referred to our hospital for further treatment. Physical examination revealed only two features of the syndrome: macroglossia and hyper-
trophy of the clitoris. Examination of her mother resulted in the same diagnosis, but her older sister did not have the syndrome. The tongue reduction surgery was performed in April 1988 according to the aforementioned technique. The postoperative course included tongue edema and lymphostasis, which gradually normalized. The tongue swelling diminished with time so that the tongue was confined within the oral cavity and regained its mobility. The patient’s condition before and 2 weeks and 6 months after surgery is shown in Fig 3. The surgery resulted in sufficient tongue reduction. Afterward, the patient was referred to an orthodontist who provided further treatment to correct the deformed mandible. The girl was examined 6 months after surgery and the tongue had almost regained its normal size. The tip of the tongue was somewhat longer as compared with normal, but moved easily. The girl was able to close her mouth with ease, applying no tension to her lips.
The aforementioned method of tongue reduction has been successfully used in two more teenagers with secondary macroglossia that developed from mandibular prognathism. References 1. Lazyuk GI: Teratology of a Man. Moscow. Medicine, 1979, P 98 2. Thoma KH: Oral Surgery, ~012. Saint Louis, MO, Mosby, 1969, p 122 3. Reinwald U: Die Operative Zungenverkleinerung aus Zahnartlicher Indikation. Dtsch Mund Kieferheilk 27:129, 1957 4. Vogel J, Milliken J, Kaban L: Macroglossia: A review of the condition and a new classification. Plast Reconstr Surg 78:715, 1986 5. Reichenbach E, Kale H, Briicl H: Chirurgische Kieferorthopidie. Leipzig, 1%5, pp 85-86 6. Bemadsky Yu I: Traumatology and Reconstructive Maxillofacial Surgery. Kiev, Higher School, 1985, p 352 7. Pichler H, Trauner R: Mund und Kieferchirurgie. Wien, 1948 8. Egyedi P, Obwegeser H: Zur Operativen Zungen Verkeinerung. Dtsch Zahn Mund Kiefer 41:16, 1964
