Use of Single Staged Nasolabial Flap in Oral Submucous Fibrosis
Condition: Oral Submucous Fibrosis
MeSH terms: Oral Submucous Fibrosis; Fibrosis
Study type: Interventional

Summary: 
      Long standing oral submucous fibrosis(OSMF) is associated with involvement

      of the oral submucosa and the muscles of mastication leading to difficulty in mouth

      opening. Various surgical modalities are mentioned for release but each has its own
      limitations.The aim of the study was to evaluate the change in mouth opening in patients of
      OSMF after excision of fibrous bands followed by coronoidotomy and surgical defect coverage
      by single stage nasolabial flap.
    

Detailed description: 
      The world of medical science is replete with a plethora of conditions both physiological and
      pathological which exhibit manifold symptoms, some of which man has conquered while against
      others, he is still waging a relentless battle. In this fast changing world of stress and cut
      throat competition, we humans often resort ourselves to tension relieving habits like
      alcoholism, smoking, tobacco or betel nut chewing. Apart from the very severe systemic
      consequences of these habits, oral cavity is also very adversely affected. Of all the unique
      oral afflictions that these habits have on oral cavity of betel quid chewers, Oral Submucous
      Fibrosis (OSMF) holds a pivotal position.

      OSMF is a distressing condition in which due to limited opening of the oral cavity, the
      patient is neither able to consume a normal diet nor maintain proper oral hygiene. OSMF
      mostly occurs in Asian countries, including India ,China, Pakistan, Sri Lanka and Bangladesh,
      where chewing betel quid (areca nut , tobacco, slaked lime, or other species) is very popular
      & accepted as form of tradition in most part of these countries. It is observed that
      irritants like betel nuts, tobacco etc. if kept for longer period around the cheek and
      swallowed gradually may play a major part in the causation of the disease.

      In India, the first mention of this disease in literature dates back to time of 'Sushruta' as
      'Vidari'. However in modern literature 'Schwartz' in 1952 first described it as "Atrophica
      idiopathica mucosa oris".

      Oral submucous fibrosis is "an insidious, chronic disease affecting any part of the oral
      cavity and sometimes the pharynx. Although occasionally preceded by and/or associated with
      vesicle formation, it is always associated with a juxta-epithelial inflammatory reaction
      followed by a fibroelastic change of the lamina propria, with epithelial atrophy leading to
      stiffness of the oral mucosa causing trismus and inability to eat" Usually in this disease
      patient has no disabling symptoms in the early phase, but as it progress it causes burning
      sensation, difficulty in eating and opening of mouth, that forces patients to report a
      clinician with these distressing symptoms. Sharp (1956) has described submucous fibrosis
      along with epithelial hyperplasia and mucosal atrophy as a characteristic feature of
      abnormal-precancerous oral epithelium and of tissue adjacent to frank oral cancer. OSMF can
      transform into oral cancer, and particularly squamous-cell carcinoma, at a rate in the range
      of 7% to 13%.

      OSMF can occur in any decade of life but is commonly seen in 2nd -4th decade of life. Various
      studies have suggested multifactorial origin of the disease with high incidence associated
      with consumption of areca nut. Reduction or preferably stoppage of the habit forms an
      essential component of the total treatment plan. The mainstay in the treatment of OSMF is
      therefore concentrated upon improving mouth opening and relieving the symptoms either by
      medicinal or surgical means. The medicinal treatment for mild cases of OSMF includes
      steroids, cardiovascular drugs, antioxidants, vitamins and iron supplements. Topical
      application of steroids, hyaluronidase, collagenase, and placental extract has yielded
      positive results in mild cases but in advanced cases, surgery followed by aggressive
      physiotherapy is the only viable treatment which produces satisfactory results.

      Excision of the fibrous bands and propping the mouth open to allow secondary
      epithelialisation causes rebound fibrosis during healing. Release of fibrous bands and split
      thickness skin grafting has a high recurrence from contracture. The survival of full
      thickness skin grafts is questionable. The use of island palatal flaps based on the greater
      palatine artery as recommended by Khanna et al. has limitations including involvement of the
      donor site by fibrosis, limited donor tissue with limited reach of the flap, and the need for
      extraction of maxillary second molars to cover the defect with the flap under no tension. The
      bilateral tongue flaps cause severe dysphasia, disarticulation, 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 are the common postoperative
      complications of uncontrolled tongue movements. Apart from this the reported involvement of
      the tongue is 38%, which precludes its use for reconstruction. Buccal fat pads may also be
      used to cover the defects after excision of the fibrous bands. The harvesting of the buccal
      fat pad is simple because access is easy. However, severe atrophy of buccal fat pads is seen
      in patients with chronic disease. In addition, the anterior reach of the buccal fat pad is
      often inadequate, and the region anterior to the cuspid is required to be left raw. This raw
      area heals by secondary intention and subsequently fibrosis, leading to gradual relapse.
      Bilateral radial forearm free flaps are hairy, 40% of patients require secondary debulking
      procedures, and the facilities for free tissue transfer are not universally available.
      Canniff and Harvey recommended temporal myotomy or coronoidectomy to release severe trismus
      caused by the atrophic changes in the tendon of temporalis muscle secondary to the disease.

      The use of the nasolabial flap in reconstruction of head and neck defects has proved to be
      efficacious and reliable. The versatility of this flap has been attributed to the fact that
      there is often abundant non - hair bearing skin in this well vascularized region. Also the
      proximity to the defect and achievement of good cosmetic result with preservation of function
      and least distortion of anatomy makes it the flap of choice. Therefore, these advantages of
      'extended single stage nasolabial flap' in the treatment of OSMF led us to carry out this
      study for "Evaluation of change in mouth opening in centimeters in oral submucous fibrosis
      patients after surgical excision of fibrous bands along with bilateral coronoidotomy &
      surgical defect coverage by single stage nasolabial flap". Mouth opening in centimeters was
      recorded pre operatively(base line),to 1 week,2 week,3 week,4 week, 2nd month,3rd month and 6
      month post operatively and the change was recorded.
    

Intervention name(s): single stage nasolabial flap
Intervention type(s): Procedure
Intervention description(s): The versatility of this flap has been attributed to the fact that there is often abundant non-hair-bearing skin in this well-vascularized region. The facial and infraorbital arteries are frequently cited in anatomic descriptions of the nasolabial flap. The venous drainage is believed to be via the angular and facial veins.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment