Tongue Flap Reconstruction in Cancer of the Oral Cavity Donald G.
Sessions, MD; Douglas D. Dedo, MD; Joseph H. Ogura, MD
The mobility, size, and composition of the tongue make it ideal for oral cavity reconstruction following resection for carcinoma. The tongue flap provides a ready means of primary closure without increased morbidity, especially in patients who have had extensive therapeutic or preoperative irradiation treatment. The position of the tongue adjacent to the surgical defect and its excellent blood supply allow its nondelayed utilization. In most cases, use of the tongue flap precludes the necessity for multiple staged reconstruction with regional pedicle flaps, with an improvement in functional results in terms of immediate healing, swallowing, and articulation over previous methods of reconstruction.
high
Theated
rate of
success
Accepted for publication Aug 12, 1974. Read before the Tenth Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Inc., Palm Beach, Fla, April From the
Department
Washington University Louis.
of
lateral flow to the tongue and that ligation of the lingual artery on the involved side may be performed with¬ out
CLINICAL MATERIAL The charts of all patients with epider¬ moid carcinoma of the oral cavity treated by the Otolaryngology Service at Barnes Hospital, St. Louis Veterans Adminis¬ tration Hospital, St. Louis City Hospital, and Jewish Hospital of St. Louis, from 1970 to 1973 were reviewed. During this period, 123 patients with carcinoma of the oral cavity were treated surgically. Review of the operative notes revealed 28 of these patients had reconstruction with a tongue flap. The Table summarizes primary site and clinical stage of the tumors resected in these patients.
TECHNIQUES
Medicine, St.
Reprint requests to the Department of Otolaryngology, Washington University School of Medicine, 517 S Euclid, St. Louis, MO 63110 (Dr. Sessions).
De¬
artery.
Otolaryngology,
School of
impairing flap viability.1·2
Santo3 divided the ipsilaterai lingual artery in 15 of 26 tongue flap recon¬ structions without morbidity. He be¬ lieved this was due to anastomotic collaterals of the dorsal lingual, sublingual, and deep lingual ranine branches of the lingual artery and collaterals from the submental branch of the facial artery and the tonsillar branches of the palatine
associ¬
with the use of tongue flaps is due to the rich blood supply of the tongue.1 The lingual artery pene¬ trates the substance of the tongue from a posterior and inferior aspect and arborizes all the way out to the tip. Although the major blood supply
21, 1974.
is from the lingual artery, it is well recognized that there is excellent col¬
Care is taken during the resection of the primary lesion to preserve the external ca¬ rotid artery where possible. The size of the pedicled tongue flap depends on the defect
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
and Clinical Stage of Patients Reconstructed With Tongue
remaining following the resection. Al¬ though there may be superficial extension
Primary Site
Site Floor of mouth Alveolar process of mandible Tonsil
Flap
No. of Cases 18
3
11
4
13
Tongue
Anterior 2/3 Posterior 1/3
Soft palate Buccal Retromolar trigone Totals
1 28
6
...
.
Ì3
_1_1_ 18 9
ÎÔ~
of tumor onto the interior and lateral sur¬ face of the tongue, there must be enough mucosa and muscle on the dorsum of the tongue to rotate into the defect. Figure 1 indicates the technique of forming the pos¬ teriorly based tongue flap and rotating it into the defect. The tongue is divided from near the tip to the circumvallate line. This is done slowly, with scissors, using a spread-and-cut technique in order to pre¬ serve as much lingual artery in the flap as possible. In this manner, medially ar¬ borizing vessels may be ligated leaving the main lingual artery intact. Increased length is obtained by carrying the poste¬ rior division obliquely lateral. Increase in width may be obtained by filleting the flap with multiple small incisions in the long axis. The tongue flap is then rotated in¬ to the defect and sutured to the mucosal edge. Twisting the pedicle either to close a contralateral floor of mouth defect or to close a pharyngeal wall defect appears to be well tolerated. The flap used for recon¬ struction is usually denervated temporar¬ ily by clamping the ipsilaterai hypoglossal nerve in the neck. The hypoglossal nerve is not sectioned. The remaining portion of the hemitongue with its own blood and nerve supply is functionally mobile be¬ cause the flap itself is cut posteriorly to the level of the circumvallate line. If the flap were not divided that far posteriorly, then the remaining portion of the tongue would be tied down anteriorly and thus, could not be mobile. The edges of the anterior two thirds of the preserved portion of the tongue are sutured to each other. This re¬ sults in a narrowed but mobile tip with which the patient can swallow and articu¬ late. The raw surface between the tongue and the tongue flap is left uncovered.
RESULTS
The 28
patients
who underwent
were fol¬ lowed from six to 36 months. There was no immediate operative morbid¬ ity and no mortality associated with
tongue flap reconstruction
Fig 1.—Technique of tongue flap recon¬ struction. Following resection of the can¬ cer (A), the tongue is divided full thick¬ ness from near the tip to the circumvallate line (B). Increase in length may be ob¬ tained by carrying the posterior incision obliquely lateral (C). Tongue flap is ro¬ tated into the defect and the edges of the anterior two thirds of the preserved por¬ tion of the tongue are sutured to each other (D).
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
the procedure. Operative time and blood loss were substantially de¬ creased over forehead flap reconstruc¬ tion. All complications occurred within six weeks of surgery. Four pa¬ tients sloughed the superficial layer of the tongue flap at the anterior mucosal anastomosis within ten days after surgery. Each of these flaps healed without serious sequelae. Three patients developed oral-cutane¬ ous fistulas that healed spontane¬
ously.
Two patients had difficulty swal¬ lowing postoperatively. One of these patients required surgical debulking of the tongue flap (40 days postresection) to permit construction of a dental prosthesis with which to swal¬ low. The second patient with post¬ operative dysphagia was initially treated with radium implants and ex¬
ternal irradiation for carcinoma of the floor of the mouth. Five years later he was found to have recurrent tumor and an additional 3,000 rads was given preoperatively. A compos¬ ite resection with tongue flap re¬ construction was performed with sat¬ isfactory immediate healing. The mobile tongue remnant was scarred down and articulation and swallow¬ ing were unsatisfactory. Seven months later a tongue release was performed without success. Presently articulation continues to be poor and intake is per nasogastric tube. One patient had sloughing of the anterior one third of the mobile tongue tip. This started about three days postoperatively and autoam-
putation occurred at six days. Inter¬ estingly, he swallows very well and
has fair articulation with his remain¬ ing mobile tongue. We have no expla¬ nation for this complication although Chambers and associates1 have de¬ scribed it previously. COMMENT
The goals of reconstruction follow¬ ing resection of cancer of the oral cavity include satisfactory healing, and adequate lingual function in¬ cluding swallowing and articulation. Many procedures have been used to
achieve a solution to this reconstruc¬ tive problem. Procedures
reconstruction: planned orostome pharyngostome with subsequent staged flap closure
Delayed or
Immediate reconstruction
split tongue as a rotational pedicle. They described this technique in the reconstruction of soft palate and ton¬
Primary closure
Direct closure1·4 Skin graft closure1·4" Dermal graft closure7 Local flap Mucosal flap1
Tongue flap13·5 Regional flap Forehead flap1·5·8·" Cervical flap51011
Immediate reconstruction is almost
always possible following oral cavity cancer resection. Rarely is a planned orostome or pharyngostome necessary. Direct primary closure of oral cavity defects is the most common recon¬ structive maneuver. However, there are many defects where primary clo¬ sure using the undivided tongue will
Fig 2.—Tongue flap, two-year follow-up, shows pliable, fully mobile tongue (left right). Articulation is very satisfactory and swallowing is entirely normal.
result in a functional oral cripple. The use of skin and dermal grafts in clo¬ sure of buccal, palatal, and tonsillar defects is standard but this is of little value in closing floor of the mouth de¬ fects. Mucosal flaps are of value only for defects of the palate and buccal areas. Regional flaps, especially fore¬ head flaps, may provide excellent functional results but require a planned multistage approach and are not without complications, including fistula formation, facial paralysis, os¬ teomyelitis, and flap necrosis.8 At the present time, tongue flaps appear to offer the best solution for immediate reconstruction of oral cav¬ ity defects with satisfactory healing and little loss of function. Rarely is a second surgical procedure necessary. Klopp and Shurter2 were the first to describe the use of the longitudinally
and
sillar defects. Since that time this versatile flap has been used success¬ fully for reconstruction of defects of the buccal wall,12 floor of mouth,3·513 lip,11·1415 hard palate,15 lateral wall of the pharynx,3 and mandible and cer¬ vical esophagus.16 The results in using pedicled tongue flaps have been almost uni¬ formly successful. The resulting tongue remnant is mobile and pliable and in most cases fully functional (Fig 2). The low complication rate at¬ tests to the rich blood supply of the flap. The primary problem has been superficial necrosis of the tongue flap at the mucosal junction anterior¬ ly.1·5·13 This has invariably resulted in
delayed spontaneous healing. Although certain authors1·3 have not noted an increase in complica¬ tions following presurgical or thera¬ peutic irradiation, our experience and
that of others5·13 shows that increased problems do occur in this patient pop¬ ulation. Necrosis of the tip of the remaining tongue is the most severe problem following the use of the tongue flap.1 This may require subsequent mobili¬ zation of the tongue flap for use in
swallowing.
Patients with a history of massive irradiation or implant to the tongue
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
and floor of the mouth should not have tongue flap reconstruction. We believe that this is one of the positive indications for bringing in regional tissue and we prefer the forehead
flap.8·9
The tongue flap is of special value when used in conjunction with re¬ gional flaps in the reconstruction of
large defects where skin and mucosa have been resected. The tongue flap is used as the inner lining of the oral cavity in these patients. The tongue flap has been used successfully to re¬ pair full thickness buccal and man¬ dibular defects. For buccal recon¬ struction we have used the tongue flap with an ipsilaterai full forehead
flap;
and for full thickness chin and mandibular defects we have used the tongue flap in conjunction with a staged medially based chest flap. Supported in part by National Institutes of Health Training grant No. 5T01 NSO 5190-15 from the National Institute of Neurological Dis¬ eases and Stroke.
References 1. Chambers RG, Jaques DA, Mahoney WD: Tongue flaps for intraoral reconstruction. Am J Surg 118:783, 1969. 2. Klopp CT, Shurter M: The surgical treatment of cancer of the soft palate and tonsil. Can-
9:1239, 1956. 3. DeSanto LW: Lingual flap reconstruction after resection for cancer. Trans Am Acad Ophthalmol Otolaryngol 78:135-139, 1974. 4. Corso P, Gerald F: Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new method. Am J Surg 104:727-731, 1963. 5. Som ML, Nussbaum M: Marginal resection of the mandible with reconstruction by tongue flap for carcinoma of the floor of the mouth. Am cer
J
Surg 121:679-683, 1971. 6. Helsper JT, Fister HW:
Use of skin grafts in the mouth in the management of oral cancer. Am J Surg 114:596-600, 1967. 7. Read GF: Use of dermal grafts in otolaryngology. Ann Otol Rhinol Laryngol 74:769-784, 1965. 8. Biller HF, Ogura JH, Brownson RJ: The forehead flap. Arch Otolaryngol 97:316-318,1973. 9. Sessions DG, Stallings JO, Brownson RJ, et al: Total glossectomy for advanced carcinoma of the base of the tongue. Laryngoscope 83:39-50, 1973. 10. Myers EN: Reconstruction of the oral cavity. Otolaryngol Clin North Am 5:421-422, 1972. 11. Bakamjian V: Use of tongue flaps in lower
lip
reconstruction. Br J Plastic
1964. 12.
Surg 17:76-87,
Ganguli A: Use of tongue flap to line cheek defects in surgery for cancer. Plast Reconstr Surg 41:390-392, 1968. 13. Papaioannou AN, Farr HW: Reconstruction of the floor of the mouth by a pedicle tongue flap. Surg Gynec Obstet 122:807-810, 1966. 14. Guerrero-Santos J, Alltamirano JT: Use of lingual flaps in repair of fistulas of the hard and soft palate. Plast Reconstr Surg 38:123-128,1966. 15. McGregor IA: The tongue flap in lip surgery. Br J Plast Surg 19:253-263, 1966. 16. Conley JJ, DeAmest F, Pierce MK: The use of tongue flaps in head and neck surgery. Surgery 41:745-751, 1957.
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
Sessions, MD; Douglas D. Dedo, MD; Joseph H. Ogura, MD
The mobility, size, and composition of the tongue make it ideal for oral cavity reconstruction following resection for carcinoma. The tongue flap provides a ready means of primary closure without increased morbidity, especially in patients who have had extensive therapeutic or preoperative irradiation treatment. The position of the tongue adjacent to the surgical defect and its excellent blood supply allow its nondelayed utilization. In most cases, use of the tongue flap precludes the necessity for multiple staged reconstruction with regional pedicle flaps, with an improvement in functional results in terms of immediate healing, swallowing, and articulation over previous methods of reconstruction.
high
Theated
rate of
success
Accepted for publication Aug 12, 1974. Read before the Tenth Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Inc., Palm Beach, Fla, April From the
Department
Washington University Louis.
of
lateral flow to the tongue and that ligation of the lingual artery on the involved side may be performed with¬ out
CLINICAL MATERIAL The charts of all patients with epider¬ moid carcinoma of the oral cavity treated by the Otolaryngology Service at Barnes Hospital, St. Louis Veterans Adminis¬ tration Hospital, St. Louis City Hospital, and Jewish Hospital of St. Louis, from 1970 to 1973 were reviewed. During this period, 123 patients with carcinoma of the oral cavity were treated surgically. Review of the operative notes revealed 28 of these patients had reconstruction with a tongue flap. The Table summarizes primary site and clinical stage of the tumors resected in these patients.
TECHNIQUES
Medicine, St.
Reprint requests to the Department of Otolaryngology, Washington University School of Medicine, 517 S Euclid, St. Louis, MO 63110 (Dr. Sessions).
De¬
artery.
Otolaryngology,
School of
impairing flap viability.1·2
Santo3 divided the ipsilaterai lingual artery in 15 of 26 tongue flap recon¬ structions without morbidity. He be¬ lieved this was due to anastomotic collaterals of the dorsal lingual, sublingual, and deep lingual ranine branches of the lingual artery and collaterals from the submental branch of the facial artery and the tonsillar branches of the palatine
associ¬
with the use of tongue flaps is due to the rich blood supply of the tongue.1 The lingual artery pene¬ trates the substance of the tongue from a posterior and inferior aspect and arborizes all the way out to the tip. Although the major blood supply
21, 1974.
is from the lingual artery, it is well recognized that there is excellent col¬
Care is taken during the resection of the primary lesion to preserve the external ca¬ rotid artery where possible. The size of the pedicled tongue flap depends on the defect
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
and Clinical Stage of Patients Reconstructed With Tongue
remaining following the resection. Al¬ though there may be superficial extension
Primary Site
Site Floor of mouth Alveolar process of mandible Tonsil
Flap
No. of Cases 18
3
11
4
13
Tongue
Anterior 2/3 Posterior 1/3
Soft palate Buccal Retromolar trigone Totals
1 28
6
...
.
Ì3
_1_1_ 18 9
ÎÔ~
of tumor onto the interior and lateral sur¬ face of the tongue, there must be enough mucosa and muscle on the dorsum of the tongue to rotate into the defect. Figure 1 indicates the technique of forming the pos¬ teriorly based tongue flap and rotating it into the defect. The tongue is divided from near the tip to the circumvallate line. This is done slowly, with scissors, using a spread-and-cut technique in order to pre¬ serve as much lingual artery in the flap as possible. In this manner, medially ar¬ borizing vessels may be ligated leaving the main lingual artery intact. Increased length is obtained by carrying the poste¬ rior division obliquely lateral. Increase in width may be obtained by filleting the flap with multiple small incisions in the long axis. The tongue flap is then rotated in¬ to the defect and sutured to the mucosal edge. Twisting the pedicle either to close a contralateral floor of mouth defect or to close a pharyngeal wall defect appears to be well tolerated. The flap used for recon¬ struction is usually denervated temporar¬ ily by clamping the ipsilaterai hypoglossal nerve in the neck. The hypoglossal nerve is not sectioned. The remaining portion of the hemitongue with its own blood and nerve supply is functionally mobile be¬ cause the flap itself is cut posteriorly to the level of the circumvallate line. If the flap were not divided that far posteriorly, then the remaining portion of the tongue would be tied down anteriorly and thus, could not be mobile. The edges of the anterior two thirds of the preserved portion of the tongue are sutured to each other. This re¬ sults in a narrowed but mobile tip with which the patient can swallow and articu¬ late. The raw surface between the tongue and the tongue flap is left uncovered.
RESULTS
The 28
patients
who underwent
were fol¬ lowed from six to 36 months. There was no immediate operative morbid¬ ity and no mortality associated with
tongue flap reconstruction
Fig 1.—Technique of tongue flap recon¬ struction. Following resection of the can¬ cer (A), the tongue is divided full thick¬ ness from near the tip to the circumvallate line (B). Increase in length may be ob¬ tained by carrying the posterior incision obliquely lateral (C). Tongue flap is ro¬ tated into the defect and the edges of the anterior two thirds of the preserved por¬ tion of the tongue are sutured to each other (D).
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
the procedure. Operative time and blood loss were substantially de¬ creased over forehead flap reconstruc¬ tion. All complications occurred within six weeks of surgery. Four pa¬ tients sloughed the superficial layer of the tongue flap at the anterior mucosal anastomosis within ten days after surgery. Each of these flaps healed without serious sequelae. Three patients developed oral-cutane¬ ous fistulas that healed spontane¬
ously.
Two patients had difficulty swal¬ lowing postoperatively. One of these patients required surgical debulking of the tongue flap (40 days postresection) to permit construction of a dental prosthesis with which to swal¬ low. The second patient with post¬ operative dysphagia was initially treated with radium implants and ex¬
ternal irradiation for carcinoma of the floor of the mouth. Five years later he was found to have recurrent tumor and an additional 3,000 rads was given preoperatively. A compos¬ ite resection with tongue flap re¬ construction was performed with sat¬ isfactory immediate healing. The mobile tongue remnant was scarred down and articulation and swallow¬ ing were unsatisfactory. Seven months later a tongue release was performed without success. Presently articulation continues to be poor and intake is per nasogastric tube. One patient had sloughing of the anterior one third of the mobile tongue tip. This started about three days postoperatively and autoam-
putation occurred at six days. Inter¬ estingly, he swallows very well and
has fair articulation with his remain¬ ing mobile tongue. We have no expla¬ nation for this complication although Chambers and associates1 have de¬ scribed it previously. COMMENT
The goals of reconstruction follow¬ ing resection of cancer of the oral cavity include satisfactory healing, and adequate lingual function in¬ cluding swallowing and articulation. Many procedures have been used to
achieve a solution to this reconstruc¬ tive problem. Procedures
reconstruction: planned orostome pharyngostome with subsequent staged flap closure
Delayed or
Immediate reconstruction
split tongue as a rotational pedicle. They described this technique in the reconstruction of soft palate and ton¬
Primary closure
Direct closure1·4 Skin graft closure1·4" Dermal graft closure7 Local flap Mucosal flap1
Tongue flap13·5 Regional flap Forehead flap1·5·8·" Cervical flap51011
Immediate reconstruction is almost
always possible following oral cavity cancer resection. Rarely is a planned orostome or pharyngostome necessary. Direct primary closure of oral cavity defects is the most common recon¬ structive maneuver. However, there are many defects where primary clo¬ sure using the undivided tongue will
Fig 2.—Tongue flap, two-year follow-up, shows pliable, fully mobile tongue (left right). Articulation is very satisfactory and swallowing is entirely normal.
result in a functional oral cripple. The use of skin and dermal grafts in clo¬ sure of buccal, palatal, and tonsillar defects is standard but this is of little value in closing floor of the mouth de¬ fects. Mucosal flaps are of value only for defects of the palate and buccal areas. Regional flaps, especially fore¬ head flaps, may provide excellent functional results but require a planned multistage approach and are not without complications, including fistula formation, facial paralysis, os¬ teomyelitis, and flap necrosis.8 At the present time, tongue flaps appear to offer the best solution for immediate reconstruction of oral cav¬ ity defects with satisfactory healing and little loss of function. Rarely is a second surgical procedure necessary. Klopp and Shurter2 were the first to describe the use of the longitudinally
and
sillar defects. Since that time this versatile flap has been used success¬ fully for reconstruction of defects of the buccal wall,12 floor of mouth,3·513 lip,11·1415 hard palate,15 lateral wall of the pharynx,3 and mandible and cer¬ vical esophagus.16 The results in using pedicled tongue flaps have been almost uni¬ formly successful. The resulting tongue remnant is mobile and pliable and in most cases fully functional (Fig 2). The low complication rate at¬ tests to the rich blood supply of the flap. The primary problem has been superficial necrosis of the tongue flap at the mucosal junction anterior¬ ly.1·5·13 This has invariably resulted in
delayed spontaneous healing. Although certain authors1·3 have not noted an increase in complica¬ tions following presurgical or thera¬ peutic irradiation, our experience and
that of others5·13 shows that increased problems do occur in this patient pop¬ ulation. Necrosis of the tip of the remaining tongue is the most severe problem following the use of the tongue flap.1 This may require subsequent mobili¬ zation of the tongue flap for use in
swallowing.
Patients with a history of massive irradiation or implant to the tongue
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
and floor of the mouth should not have tongue flap reconstruction. We believe that this is one of the positive indications for bringing in regional tissue and we prefer the forehead
flap.8·9
The tongue flap is of special value when used in conjunction with re¬ gional flaps in the reconstruction of
large defects where skin and mucosa have been resected. The tongue flap is used as the inner lining of the oral cavity in these patients. The tongue flap has been used successfully to re¬ pair full thickness buccal and man¬ dibular defects. For buccal recon¬ struction we have used the tongue flap with an ipsilaterai full forehead
flap;
and for full thickness chin and mandibular defects we have used the tongue flap in conjunction with a staged medially based chest flap. Supported in part by National Institutes of Health Training grant No. 5T01 NSO 5190-15 from the National Institute of Neurological Dis¬ eases and Stroke.
References 1. Chambers RG, Jaques DA, Mahoney WD: Tongue flaps for intraoral reconstruction. Am J Surg 118:783, 1969. 2. Klopp CT, Shurter M: The surgical treatment of cancer of the soft palate and tonsil. Can-
9:1239, 1956. 3. DeSanto LW: Lingual flap reconstruction after resection for cancer. Trans Am Acad Ophthalmol Otolaryngol 78:135-139, 1974. 4. Corso P, Gerald F: Immediate and secondary reconstruction of the floor of the mouth and mobilization of the tongue by a new method. Am J Surg 104:727-731, 1963. 5. Som ML, Nussbaum M: Marginal resection of the mandible with reconstruction by tongue flap for carcinoma of the floor of the mouth. Am cer
J
Surg 121:679-683, 1971. 6. Helsper JT, Fister HW:
Use of skin grafts in the mouth in the management of oral cancer. Am J Surg 114:596-600, 1967. 7. Read GF: Use of dermal grafts in otolaryngology. Ann Otol Rhinol Laryngol 74:769-784, 1965. 8. Biller HF, Ogura JH, Brownson RJ: The forehead flap. Arch Otolaryngol 97:316-318,1973. 9. Sessions DG, Stallings JO, Brownson RJ, et al: Total glossectomy for advanced carcinoma of the base of the tongue. Laryngoscope 83:39-50, 1973. 10. Myers EN: Reconstruction of the oral cavity. Otolaryngol Clin North Am 5:421-422, 1972. 11. Bakamjian V: Use of tongue flaps in lower
lip
reconstruction. Br J Plastic
1964. 12.
Surg 17:76-87,
Ganguli A: Use of tongue flap to line cheek defects in surgery for cancer. Plast Reconstr Surg 41:390-392, 1968. 13. Papaioannou AN, Farr HW: Reconstruction of the floor of the mouth by a pedicle tongue flap. Surg Gynec Obstet 122:807-810, 1966. 14. Guerrero-Santos J, Alltamirano JT: Use of lingual flaps in repair of fistulas of the hard and soft palate. Plast Reconstr Surg 38:123-128,1966. 15. McGregor IA: The tongue flap in lip surgery. Br J Plast Surg 19:253-263, 1966. 16. Conley JJ, DeAmest F, Pierce MK: The use of tongue flaps in head and neck surgery. Surgery 41:745-751, 1957.
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
