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British Journal of Oral and Maxillofacial Surgery 47 (2009) 382–385

Extended nasolabial flaps in the management

of oral submucous fibrosis
R.M. Borle ∗ , P.V. Nimonkar, R. Rajan
Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Datta Meghe Institute of Medical Sciences,
University, Sawangi (M), Wardha, (MS), India

Accepted 29 August 2008

Available online 7 November 2008

Abstract

We evaluated the use of extended nasolabial flaps and coronoidectomy in the management of 47 randomly selected patients with histologically
confirmed oral submucous fibrosis. They all had interincisal opening of less than 25 mm and were treated by bilateral release of fibrous
bands, coronoidectomy or coronoidotomy, and extended grafting with a nasolabial flap. All patients had postoperative physiotherapy, and
were followed up for 2 years. Their interincisal opening improved significantly from a mean of 14 mm (range 3–23) to a mean of 41 mm
(range 23–55). The procedure was effective in the management of patients with oral submucous fibrosis, the main disadvantage being the
extraoral scars.
© 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Introduction We propose a new protocol for the management of

oral submucous fibrosis, which highlights the importance
Oral submucous fibrosis is an insidious, chronic, disabling of coronoidectomy and the use of extended nasolabial
disease of obscure aetiology that affects the entire oral cavity, flaps to provide a long-term, relapse-free, and economical
sometimes the pharynx, and rarely the larynx. It is charac- option.
terised by blanching and stiffness of the oral mucosa, which
causes progressive limitation of mouth opening and intoler-
ance to hot and spicy food.1 Patients and methods
It is an established precancerous condition with increased
prevalence in the Indian subcontinent. Its precancerous nature Forty-seven consecutive patients (46 men and 1 woman
was first described by Paymaster,2 who recorded the onset of aged between 18 and 44 years of age), were randomly
slowly growing squamous cell carcinomas in one third of selected. All patients had interincisal opening of less than
patients with it. Minti et al reported a malignant transforma- 25 mm.
tion rate of 7.6%.3 The patients were operated on under general anaesthe-
As the aetiology is uncertain, its treatment has largely been sia given through a nasoendotracheal tube using a fibreoptic
symptomatic. Various treatments have been described with bronchoscope. Incisions were placed bilaterally on the buc-
inconsistent results.4 cal mucosa using an electrosurgical knife; they extended from
the corner of mouth to the soft palate at the level of the linea
alba, and avoided injury to Stenson’s duct. After fibrous bands
∗ Corresponding author.
had been released the interincisal opening was recorded. The
Tel.: +91 7152 240808x245967x245968x240129; fax: +91 7152 241711.
coronoid processes were approached through the same inci-
E-mail addresses: [email protected] (R.M. Borle), sions and a bilateral coronoidectomy or coronoidotomy was
[email protected] (P.V. Nimonkar). carried out. The maxillary and mandibular third molars were

0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.08.019
 R.M. Borle et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 382–385 383

Fig. 1. (a) Illustrating design of nasolabial flap. (b) Raising of nasolabial flap and creating of transbuccal tunnel.

extracted. Extended nasolabial flaps from the tip of nasolabial The transposed nasolabial flaps were widened from a
fold to the inferior border of mandible were bilaterally raised 10 mm to the mean of 27 (range 20–29) mm after physio-
in the plane of the superficial musculoaponeurotic system therapy (Fig. 3).
from both terminal points to the region of the central pedi- The interincisal opening improved significantly from a
cle. The pedicle was 1 cm lateral to the corner of mouth and mean (range) of 14 (3–23) mm to 41 (23–55) mm at the end
the diameter of the pedicle was roughly 1 cm. The flap was of 6 months and persisted without relapse for 2 years of follow
transposed intraorally through a small transbuccal tunnel near up.
the commissure of the mouth, with no tension (Fig. 1). The Four patients had unsatisfactory mouth opening because
transposed flaps were used to cover the intraoral defects. The of poor compliance.
inferior wing of the flap was sutured to the anterior edge The transposed flaps were covered with mucosa by the
of the defect, while the superior wing was sutured to the end of 2 years, and the growth of hair was also significantly
posterior edge of the defect. The extraoral defect was closed reduced.
primarily in layers after liberal undermining of the skin in the
subcutaneous plane to prevent any tension across the suture
line.
A soft temporomandibular joint trainer was placed postop-
eratively in the oral cavity for 10 days to prevent dehiscence
of the flap as a result of occlusal trauma. After a latent period
of 10 days, physiotherapy was started with the help of Heis-
ter’s jaw exerciser to prevent contractures and relapse. The
patients were instructed and motivated to continue the phys-
iotherapy themselves for up to 6 months and were followed
up for 2 years.

Results

The mean (range) increase in interincisal opening after bilat-

eral release of the fibrous bands was 18 (range 23–46) mm
and there was further improvement of 17 mm (range 41–52)
after bilateral release or excision of the coronoid processes
(Table 1).

Table 1
Interincisal mouth opening (mm) (n = 47).
Period Mean (range)
Preoperatively 14 (–)
After release of fibrous bands 32 (–)
After bilateral coronoidectomy or coronoidotomy 49 (–)
Fig. 2. Showing widening of oral commissure in the immediate Postopera-
Two years postoperatively 41 (–)
tive period.
384 R.M. Borle et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 382–385

Table 2
Widening of the oral commissure (mm) (n = 47).
Period Mean (range)
Preoperatively 46 (–)
Postoperatively 61 (–)
Two years postoperatively 49 (–)

Subjectively 41 of the 47 patients reported a reduction in

the burning sensation.
There were some minor complications such as partial flap
necrosis particularly at the tips, temporary widening of the
oral commissure (Table 2, Fig. 2), unsightly extraoral scars,
subluxation of the mandible, and intraoral growth of hair
(Table 3). Fig. 3. Intraoral photo showing adequate mouth opening and adaptation of
nasolabial flap.

Discussion

Treatments for oral submucous fibrosis are mainly symp-

tomatic, because the aetiology of the disease is not fully
understood and it is progressive. Conservative treatment
includes vitamins, iron supplements; intralesional injections
of hyaluronidase, placental extracts, and steroids. Submu-
cosal injections of various drugs may produce temporary
symptomatic relief but can lead to aggravated fibrosis,
pronounced trismus, and increased morbidity from the
mechanical injury secondary to insertion of the needle and
chemical irritation from the drug.4
Operations have been proposed by different authors, with
variable success rates. Excision of the fibrous bands and prop-
ping the mouth open to allow secondary epithelialisation
causes rebound fibrosis during healing. Release of fibrous Fig. 4. Preoperative clinical photograph.
bands and split thickness skin grafting has a high recurrence
from contracture. The survival of full thickness skin grafts are the common postoperative complications of uncontrolled
is questionable.5 The use of island palatal flaps based on the tongue movements.5 Apart from this the reported involve-
greater palatine artery as recommended by Khanna et al.5 has ment of the tongue is 38%, which precludes its use for
limitations including involvement of the donor site by fibro- reconstruction.5 Buccal fat pads may also be used to cover the
sis, limited donor tissue with limited reach of the flap, and defects after excision of the fibrous bands. The harvesting of
the need for extraction of maxillary second molars to cover the buccal fat pad is simple because access is easy. However,
the defect with the flap under no tension.6
The bilateral tongue flaps cause severe dysphasia, disar-
ticulation, and carry the risk of postoperative aspiration. They
also provide a limited amount of donor tissue as their reach
is inadequate. The stability of a tongue flap and dehiscence

Table 3
Immediate and delayed complications (n = 47).
Complications No
Immediate
Subluxation 4
Distortion of commissure 1
Perforation of soft palate 1
Partial necrosis of flap 4
Postoperative infection 1
Delayed
Fish mouth 4 Fig. 5. Postoperative clinical photo showing extraoral scars.
 R.M. Borle et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 382–385 385

we have found severe atrophy of buccal fat pads in patients detection of oral SCC is not possible and the patients often
with chronic disease. In addition, the anterior reach of the report late to the hospital for treatment. Surgical management
buccal fat pad is often inadequate, and the region anterior not only relieves the trismus but also facilitates oral exam-
to the cuspid is required to be left raw. This raw area heals ination for early detection and management of malignant
by secondary intention and subsequently fibroses, leading to transformation.
gradual relapse.7
Bilateral radial forearm free flaps are hairy, 40% of
patients require secondary debulking procedures, and the References
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