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Year : 2021  |  Volume : 29  |  Issue : 2  |  Page : 90-94

Single-staged buccal reconstruction with facial artery-based bilateral nasolabial flaps for the management of severe trismus in oral submucous fibrosis

Department of Plastic and Reconstructive Surgery, Paul Brand Building, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission25-Mar-2020
Date of Acceptance28-May-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Dr. Geley Ete
Department of Plastic and Reconstructive Surgery, Paul Brand Building, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_27_20

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Background: Oral submucous fibrosis (OSMF) is a chronic disease of insidious onset predominant in the Asian subcontinent. It is a progressive condition resulting in forced closure of mouth and inability to take solid oral feeds. Having a multifactorial etiology, it is a well-known premalignant condition. Measures such as forcing the mouth open and releasing the fibrotic bands have resulted in aggravated fibrosis and disability. Aim: The aim was to evaluate the outcomes of bilateral inferiorly based nasolabial flaps in the management of severe trismus in patients with submucous fibrosis. Materials and Methods: The study included patients with progressive trismus presenting to the department of plastic surgery who underwent release and cover with nasolabial flap during the period from August 2014 to July 2018 (4 years). A total of eight patients were studied for their offending agents, the progression of the disease, the preoperative and postflap transfer, and inter-incisal distance, and this was followed up for a period of 1 year. Patients were studied for their improvement in mouth opening, flap status, and donor-site scar acceptability. Results: A total of eight patients of submucous fibrosis with severe trismus were treated with nasolabial flaps and followed for an average of 1 year from 2014 to 2018. The mean preoperative inter-incisal opening of 2 mm was treated by the bilateral release of mucosal fibrous bands and covered with tunneled facial artery-based nasolabial flaps. All patients received postoperative mouth-opening physiotherapy. Their inter-incisal opening improved from a mean of 2 mm to a mean of 30.8 mm. Conclusion: Bilateral pedicled nasolabial flaps can be successfully used for long-term relief of severe trismus in OSMF. Our study showed easy elevation of bilateral flaps, adequate postoperative mouth opening, with no recurrence of disease, and no flap contracture. This small-sized flap gives good coverage of the buccal mucosa without flap redundancy and cosmetically acceptable donor site.

Keywords: Nasolabial flap, oral submucous fibrosis, submucous fibrosis

How to cite this article:
Kaur A, Ete G, Paul M K, Barreto E, Chaturvedi G. Single-staged buccal reconstruction with facial artery-based bilateral nasolabial flaps for the management of severe trismus in oral submucous fibrosis. Turk J Plast Surg 2021;29:90-4

How to cite this URL:
Kaur A, Ete G, Paul M K, Barreto E, Chaturvedi G. Single-staged buccal reconstruction with facial artery-based bilateral nasolabial flaps for the management of severe trismus in oral submucous fibrosis. Turk J Plast Surg [serial online] 2021 [cited 2023 Jan 31];29:90-4. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/90/312178

  Introduction Top

Oral submucous fibrosis (OSMF) is a chronic debilitating disease of the oral cavity, affecting approximately 5 million Indians.[1] Characterized by painful and progressive limitation of mouth opening, burning sensation, halitosis, and intolerance of hot and spicy food, it is a well-described premalignant condition.[2],[3] Various medical and surgical options have been described in the literature. Nonsurgical modalities may be beneficial in the early stages; however, most patients present in the late severe stage of the disease. Under such conditions, the surgical release of the fibrotic bands followed by resurfacing of the raw area is recommended. The tissue used for resurfacing must be pliable and noncontractile to prevent the recurrence of trismus and have minimum donor-site morbidity. Nasolabial flap, based on the branches of facial, dorsal nasal, ophthalmic, and infraorbital arteries, provides locally available pliable tissue from the redundant excess skin along the bilateral nasolabial folds. It may be superiorly or inferiorly based, and is available for reconstruction of the lower eyelid, nose, lips, and intraoral mucosal defects.[4] We describe our experience of management of patients with OSMF with severe trismus, who underwent surgical release of the buccal mucosa fibrotic buccal bands, followed by pedicled tunneled facial artery-based bilateral nasolabial flap reconstruction of the exposed buccal mucosal raw areas.

  Materials and Methods Top

The study included patients who presented with severe trismus, those with preoperative histopathological proven cases of OSMF, and those who were managed with nasolabial flap. A total of 12 patients with proven biopsy for submucous fibrosis reported in our department during the period of August 2014 to July 2018 of which eight patients of submucous fibrosis treated with nasolabial flap were included in the study. Out of the four patients who did not meet the inclusion criteria, two patients underwent release and skin grafting. The other two patients were lost to follow-up after the initial biopsy. Details of the patients were obtained from the inpatient and outpatient records and were analyzed retrospectively. Patients' age, gender, history of tobacco chewing, betel quid consumption, smoking, and alcohol consumption were checked. Their preoperative inter-incisal distance (IID) and postoperative IID at the end of 1 year were studied. Trismus was defined as severe when mouth opening (IID) was <10 mm.

Surgical technique

All cases were done under general anesthesia with nasal intubation. Intubation was done with the north pole facing adult Ring, Adair, and Elwyn endotracheal tube using fiberoptic endoscopy with an external screen which helps in visualization of the airway. The surgical incision was started from the angle of the mouth, gradually advanced to the retromolar trigone, releasing the tight fibrotic band. Subsequently, a mouth gag insertion helped in further visualization of the fibrotic buccal mucosa along its entire extent from the oral commissure to retromolar trigone, or anterior faucial pillars, as required. The submucosal tissue was excised and forwarded for biopsy. Care was taken not to injure the parotid duct. The maximum intraoperative IID was checked.

Bilateral inferiorly based nasolabial flaps were marked 1 cm lateral to the oral commissure, extending along the nasolabial fold and superiorly reaching up to 1.5 cm below the medial canthus. Inferiorly, the flap extended along the mesolabial crease, avoiding hair-bearing skin if possible [Figure 1]a and [Figure 2]b. The inferior limit of the flap depended on the length of the defect.
Figure 1: (a) A 30-year-old male with 4-mm preoperative inter-incisal distance, with bilateral nasolabial flaps marked. (b) Flap elevation and flap transfer through a tunnel. (c) The intraoral defect after excision release. (d) Intraoperative photograph of the flap inset with an arrow showing the proximal and distal ends of the flap. (e) A follow-up photograph at 20 months with an improved interincisal distance of 40 mm, with well-hidden scars in nasolabial folds

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Figure 2: (a) A 28-year-old gentleman with no mouth opening preoperatively. (b) Planned bilateral nasolabial flaps with eccentric design. (c) Inferiorly based flap elevated in the subcutaneous plane. (d) Follow-up status after 1-year with a mouth opening of 30 mm, with arrow indicating “show of flap” due to bulkiness of flap

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A flap measuring an average width of 1.5 cm was taken. Prior marking of the facial vessels and their perforator was done with the help of a handheld Doppler. The flap was designed in an ellipsoid manner with the perforator placed eccentrically to minimize the inferior hair-bearing area and maximize the nonhair-bearing superior end [Figure 2]b. The incision for the flap is started medial to the marked facial artery perforator. The facial artery perforator is identified, and the flap is raised in a subcutaneous plane [Figure 2]c. In all cases, the flaps were raised constantly of size 7 cm × 1.5 cm, which gave adequate flap size to cover the buccal defect and good closure of donor site with an aesthetically acceptable scar. They were transposed intraorally via transbuccal tunnels near the commissure close to the facial vessel branch, thereby releasing any tension at the facial vessels [Figure 3]a, [Figure 3]b, [Figure 3]c.
Figure 3: (a) Schematic depiction of flap transfer through transbuccal tunnel (b and c)

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Inset was done with the superior end of the flap sitting on the retromolar trigone and inferior end at the commissure [Figures 1]b, [Figure 1]c, [Figure 1]d. The flap was sutured on the defect with single-layered absorbable sutures. The maxillary 3rd molars were extracted in one patient bilaterally, to avoid compression of the flap. All patients were started on mouth-opening physiotherapy as soon as postoperative day 7; by then, the surgical pain had subsided and advanced with serially increasing number of stacked wooden spatulas. It was continued for 3–5 months.

  Results Top

The study showed the prevalence of OSMF predominantly in the male subgroup. An age group in the range of 27–53 years was involved with a mean age of presentation at 35.75 years. Their main presenting complaint was progressively restricted mouth opening with difficulty in eating solids. The average duration of the consumption of inciting agent was 12.4 years. The majority (n = 7) were betel quid and tobacco chewers and two were smokers. The average preoperative IID was 2 mm. Flaps with a dimension of 7 cm × 1.5 cm were elevated. The mean postoperative IID at the end of 1 year was 30.87 mm [Table 1].
Table 1: Variables and mean values

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There was no flap loss, dehiscence, or recurrence of trismus during the observation period of 1 year. Third molar extraction was required in one case to avoid flap compression and in one case, bilateral coronoidectomy was done to achieve maximum mouth opening. The donor sites healed primarily with cosmetically acceptable scars [Figure 1]e. Two patients complained of intraoral hair growth on the flap and were managed by self-trimming.

  Discussion Top

Submucous fibrosis is a progressive and irreversible condition prevalent in the Southeast Asian subcontinent, with a prevalence rate of 0.2%–0.5% in India.[1] It is postulated to be a collagen disorder affecting the submucosal layer of the oral cavity. Arecoline, the active ingredient in areca nut, which is consumed as a preparation of betel nuts and tobacco, induces fibroblasts to increase collagen production and decrease vascularity due to narrowing of blood vessels.[5],[6],[7] The premalignant nature of this condition was first described by Paymaster where he found that one-third of the patients had the onset of slow-growing squamous cell carcinoma.[2] The rate of malignant transformation is 3%–7.6%.[8]

Medical therapy is attempted in early stages with vitamin and iron supplements;[9] application of 0.5% Aloe Vera topical gel; and intralesional injection of chymotrypsin, hyaluronidase, or steroids.,[10],[11] However, the results are variable, with some having doubtful efficacy. Intralesional injections may provide temporary relief but can also cause gradually aggravated fibrosis, leading to increased surgical difficulty.

Our study shows that the disease progresses slowly with gradual worsening of symptoms, i.e., the lag period from the time of consumption of the inciting agent to the presentation of symptoms was 7.7 years. Despite noticing the symptoms early such as burning sensation in mouth with restricted mouth opening, the patients delay in seeking treatment (duration of disease 4.7 years), with the reason being the slow progression of the disease or seeking treatment with alternative medicine in the initial period (Ayurveda or homeopathy). These symptoms do not improve even after cessation of the offending agent. All patients presenting to the plastic surgery department had debilitating trismus [Table 2] IID.
Table 2: Demographic profile and variables of the patient

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Surgical intervention for moderate-to-severe cases involves excision of fibrotic bands followed by resurfacing with skin grafts,[12] tongue flaps, buccal fat pad,[13] radial artery forearm free flaps,[14] and many more. Additionally, temporalis myotomy and bilateral coronoidectomy may be required to aid mouth opening.[13],[15] Mucosal grafts are the best option but have a restricted quantity of donor tissue available. Skin grafts have a high failure rate as the recipient bed of fibrotic regions has reduced vascularity. Buccal fat pad, though better than skin graft, is limited by donor-site availability especially in case of submucous fibrosis. Bulky tongue flaps can cause disarticulation and dysphagia, especially when used bilaterally. Additionally, the tongue itself may be involved by the disease process.[15],[16] The superficial temporal fascial flap is a vascular, pliable, and flexible option that has been described along with split-thickness graft.[17] The flap is elevated via a separate incision and tunnelled below the zygomatic arch to reach the intraoral cavity. It is very invasive and time-consuming.[17] The incidence of contraction of the skin graft is high, leading to recurrence.[6]

Microvascular free flaps have revolutionized intraoral reconstruction with several advantages such as avoidance of facial scars, using the two-team approach for the simultaneous recipient and donor dissection. However, despite the successful descriptions, nasolabial flap in OSMF is superior as it is a much simpler procedure surgically, less time-consuming, and therefore economical, with reliable outcomes. In our study, we have raised ellipsoid nasolabial flap with the eccentric position of the perforator to cover the buccal defect with ease. A constant flap size of 7 cm × 1.5 cm gave good coverage of the defect even in cases with severe trismus and easy closure of the donor site with minimal morbidity. A larger flap size results in redundant flap coming in between the maxillary and mandibular molars. The flap settles well into the defect without giving a “fullness-of-mouth” appearance. We have noticed that over time, the flap becomes pliable and stretches without tension at full mouth opening. There were no cases of flap complications. No secondary procedures were done, such as thinning of the flap, as is usually required in free flaps.

Postoperative mouth opening exercises were started a week after the surgery, the interval helping the flap to settle. Intensive mouth opening exercise with graded stacking of wooden spatula helps in encouraging the patient with the exercise and results in good mouth opening over a period [Figure 2]a and [Figure 2]d. Over time, the flap becomes pliable and expands, easing the mouth opening. This expansion does not cause any redundancy of flap [Figure 4]a and [Figure 4]b.
Figure 4: (a) A 27-year-old gentleman with preoperative inter-incisal distance of 0 mm. (b) The postoperative interincisal distance of 30 mm with aesthetic nasolabial scars. (c) Intraoral picture of the flap, seen here with some hair growth, at 6 months postoperatively

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The nasolabial inferiorly based pedicled flap is based on perforators from the facial artery, with its rich vascular arcade at its base. It was popularized by Dieffenbach in the 1830s. It is a reliable, versatile flap which does not undergo contracture, and has a simple surgical technique. The donor-site scar is hidden in anatomic skin tension lines, with an even better long-term cosmesis in lax elderly skin.[8] The only drawback is the growth of hair intraorally in men [Figure 4]c. Our planning of flap in ellipsoid fashion with the eccentric location of perforator to reduce the inclusion of hair-bearing skin has helped to give a better result. This hair reduces over time as the flap undergoes mucosalization. Laser epilation may be offered to patients until then. There is a risk of malignant transformation,[8] but we have not come across a malignant change of the condition in these patients. A regular follow-up will help in the detection of malignant changes early.

  Conclusion Top

Bilateral facial artery-based nasolabial island flaps can be successfully used for long-term relief of severe trismus in OSMF. It is an easy flap to elevate and a reliable and superior choice for bilateral buccal defects in OSMF. Our study showed adequate postoperative mouth opening, with no recurrence of disease and no flap contracture. This flap gave a good pliable inner lining in the oral mucosa with cosmetically acceptable donor site scar.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Informed consent

Due surgical consent was taken from all patients as per institutional format.

  References Top

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Hou D, Fang L, Zhao Z, Zhou C, Yang M. Angular vessels as a new vascular pedicle of an island nasal chondromucosal flap: Anatomical study and clinical application. Exp Ther Med 2013;5:751-6.  Back to cited text no. 4
Prabhu RV, Prabhu V, Chatra L, Shenai P, Suvarna N, Dandekeri S. Areca nut and its role in oral submucous fibrosis. J Clin Exp Dent 2014;6:569-75.  Back to cited text no. 5
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Balaji SM. Versatility of nasolabial flaps for the management of severe trismus in oral submucous fibrosis. Indian J Dent Res 2016;27:492-7.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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