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British Journal of Oral and Maxillofacial Surgery 51 (2013) 37–40

Extended nasolabial flap compared with the platysma

myocutaneous muscle flap for reconstruction of intraoral
defects after release of oral submucous fibrosis: a
comparative study
Chandrashekhar R. Bande ∗ , Abhay Datarkar, Neeraj Khare
Department of Oral & Maxillo-Facial Surgery, Swargiya Dadasaheb Kalmegh Smruti Dental College Hospital, Wanadongari Road, Hingna, Nagpur
441110, India

Accepted 25 February 2012

Available online 1 May 2012

Abstract

We compared extended nasolabial flaps and coronoidectomy with platysma myocutaneous muscle flaps in the management of 20 randomly
selected patients with histologically confirmed oral submucous fibrosis. Ten patients were treated by release of fibrous bands, bilateral
coronoidectomy, and reconstruction with an extended nasolabial flap (nasolabial group), and the other 10 by bilateral release of fibrous
bands, coronoidectomy, and reconstruction with a platysma myocutaneous muscle flap (platysma group). In the nasolabial group the mean
preoperative interincisal mouth opening was 12 (range 3–14) mm, and in the platysma group it was 11 (3–13). All 20 patients were given
vigorous postoperative physiotherapy, and were followed up for 3 years. The interincisal mouth opening improved to 47 (35–45) mm in the
nasolabial group and 48 (41–52) mm in the platysma group. The procedures were equally effective in the management of the oral submucous
fibrosis, except that the extraoral scar was not aesthetically acceptable in the nasolabial group.
© 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Oral submucous fibrosis; Myocutaneous platysma muscle flap

Introduction of oral submucous fibrosis. As the aetiology is uncertain, its

Oral submucous fibrosis is an insidious, chronic, disabling
disease of obscure aetiology that affects the entire oral cavity,
sometimes the pharynx, and rarely the larynx. It is charac-
terised by blanching and stiffness of the oral mucosa, which
causes progressive limitation of mouth opening and intoler-
ance to hot and spicy food.
It is an established precancerous condition, which occurs
mainly on the Indian subcontinent. Its precancerous nature
was first described by Paymaster,1 who recorded the onset
of slowly growing squamous cell carcinomas in one third of
patients. Murti et al.2 reported the malignant transformation
treatment has largely been symptomatic; various treatments
have been described with inconsistent results.
We have compared two techniques of closure of the defects
after release of oral submucous fibrosis. We have used two
local flaps and emphasise the importance of coronoidectomy.
We think that the platysma myocutaneous muscle flap is a
better option than an extended nasolabial flap in terms of
extraoral facial scar for the management of oral submucous
fibrosis.3
Patients and methods

∗ Corresponding author. Tel.: +91 9822710859. Twenty consecutive patients who were treated at the Depart-
E-mail address: drcrbande@yahoo.co.in (C.R. Bande). ment of Oral and Maxillofacial Surgery, Swargiya Dada

0266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2012.02.015
38 C.R. Bande et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 37–40
Fig. 1. Harvesting of the nasolabial flap (published with the patient’s per-
mission).
Saheb Kalmegh Dental College and Hospital Hingna, Nag-
pur (18 men and 2 women aged between 18 and 41 years
of age), were randomly selected for this retrospective study,
which was approved by the institutional ethics committee.
No patient had interincisal opening of more than 25 mm.
Under aseptic conditions all patients were intubated and
general anaesthetic given through a bronchoscope. Incisions
were made using an electrosurgical knife from the corner
of the mouth to the soft palate at the level of the linea alba
avoiding injury to Stenson’s duct. The bands were cut and
the interincisal opening recorded. The coronoid processes
were approached through the same incision and bilateral
coronoidectomy or coronoidotomy done. The maxillary and
mandibular third molars were extracted.
In the nasolabial group extended nasolabial flaps as
described by Borle et al.4 were raised for grafting from the tip
of the nasolabial fold to the inferior border of the mandible.
The flaps were raised bilaterally in the plane of the superficial
musculoaponeurotic system from both terminal points to the
region of the central pedicle. The pedicle was 1 cm lateral to
the corner of the mouth and the diameter of the pedicle was
roughly 1 cm (Fig. 1). The flap was transposed intraorally
through a small transbuccal tunnel near the commissure of
the mouth without tension. The inferior wing of the flap was
sutured to the anterior edge of the defect, while the superior
wing was sutured to the posterior edge of the defect. The
extraoral defect was closed primarily in layers after liberal
undermining of the skin in the subcutaneous plane to prevent
any tension across the suture line.
In the platysma group a superiorly based platysma myocu-
taneous muscle flap was raised as described by Baur5 and
used for reconstruction of the intraoral defects. With the
neck hyperextended the proposed skin paddle was outlined
on the ipsilateral neck, below the inferior border of the
mandible (Fig. 2). The superior incision was made first and
a plane superficial to the platysma muscle was dissected
carefully cephalic to the inferior border of the mandible.
A skin incision was then made at the inferior line of
the skin paddle, with additional exposure of the platysma
Fig. 2. Harvesting of the platysma muscle myocutaneous flap (published
with the patient’s permission).
muscle inferiorly. The platysma muscle was transected
sharply at least 1 cm inferior to the edge of the skin pad-
dle, and a subplatysmal plane of dissection developed just
below the inferior border of mandible. If the cervical branch
of the facial nerve was to be incorporated, it was neces-
sary to identify the nerve in the superficial layer of the
deep cervical fascia and carefully dissect and preserve its
proximal portion. Once the plane of dissection was fully
developed, the platysma myocutaneous flap was transected
vertically, anteriorly, and posteriorly for full mobilisation.
The flap was introduced into the oral defect by creating an
approximately sized soft tissue tunnel. The harvested flap
was sutured to the defect, which was created by release of
a fibrous band. The donor site was easily closed in lay-
ers to obtain an acceptable cosmetic result as shown in
(Fig. 3b).
A soft temporomandibular joint trainer was placed in the
oral cavity postoperatively 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 Hister’s
jaw exerciser to prevent contracture and relapse. The patient
was instructed in the exercises and told to do them for up to
6 months until they were followed up in the Department of
Oral and Maxillofacial Surgery.
We used Student’s unpaired t test for statistical analysis.
Results
There were 2 groups of 10 patients each, one of which had
nasolabial flaps, and the other platysma myocutaneous flaps.
The differences in mouth opening are shown in Table 1. All
 C.R. Bande et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 37–40 39

Table 1
Measurements compared between the nasolabial and platysma groups
(n = 10 in each). Data are mean (range) mm.
Variables Nasolabial Platysma
Interincisal mouth opening (mm)
Preoperatively 12 (3–14) 11 (3–13)
After release of 33 (18–36) 34 (17–37)
fibrous bands
After bilateral 47 (35–55) 48 (41–52)
coronoidec-
tomy/coronoidotomy
One year 40 (mm) 41 (mm)
postoperatively
Widening or oral commissure (mm)
Preoperatively 46 (40–50) 46 (40–50)
Postoperatively 61 (55–65) 46 (mm)
Three years 49 (mm) 46 (mm)
postoperatively
Presence of extraoral Yes No
scar

patients in the nasolabial group developed extraoral scars,

compared with none in the platysma group. The differences
in mouth opening before and after operation were significant
in both groups (p < 0.01).
There were some complications in the nasolabial group
including partial flap necrosis, particularly at the tips, tem-
porary widening of the oral commissure, unsightly extraoral
scars as shown in (Fig. 3a), subluxation of the temporo-
mandibular joint, perforation of the palate, and intraoral
growth of hair. In the platysma group a few patients devel-
oped temporary paraesthesia, which was noticed over the
lateral cervical region, subluxation of the mandible, and a
scar on the neck that is covered by the collar of the shirt, and
was not visible. There were no delayed complications in the
platysma group, but 2 patients in the nasolabial group had a
“fish mouth” deformity, even after a year (Table 2).

Discussion

The treatment of oral submucous fibrosis is mainly symp-

tomatic, because the aetiology is not fully understood
and it is progressive. Conservative treatments include vita-
mins, iron supplementation, and intralesional injections of Fig. 3. (a) Patient who had a nasolabial flap showing the extraoral scar
hyaluronidase, placental extract, and steroid. Submucosal (published with the patient’s permission) and (b) patient who had a platysma
injection of various drugs may produce temporary symp- myocutaneous flap with no sign of an extraoral scar (published with the
patient’s permission).
tomatic relief but can lead to aggravated fibrosis, pronounced
Table 2
Complications (n = 10 in each group). trismus, and increased morbidity from the mechanical injury
Complication Nasolabial Platysma secondary to needle prick injury.6
Immediate
Different operations have been proposed by various
Subluxation 2 2 authors with variable success rates. Excision of fibrous bands
Distortion of commissure 1 0 and propping the mouth open to allow secondary epithe-
Perforation of soft palate 2 1 lisation causes rebound fibrosis during healing. Release of
Partial necrosis of flap 1 1 fibrous bands followed by split thickness skin grafting results
Delayed
Fish mouth 2 0
in a high recurrence rate from contracture. The survival of full
thickness skin grafts is questionable. The use of an island
40 C.R. Bande et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 37–40
palatal flap on the greater palatine artery was recommended
by Khanna et al., but has limitations including involvement
of donor tissue with the limited reach of the flap, and the
need for extraction of the maxillary second molar to lower
the defect so that the flap is under no tension.7
The bilateral tongue flap causes severe dysphagia and dis-
articulation, and carries the risk of postoperative aspiration.
It also provides a limited amount of donor tissue as its reach
is inadequate. The doubtful stability of a tongue flap and
dehiscence are the common postoperative complications of
uncontrolled tongue movements.8 Buccal fat pads may also
be used to cover the defects after excision of fibrous bands,
and their harvest is simple. However, in patients with chronic
disease they are likely to be atrophic. In addition, the anterior
reach of buccal fat pads is inadequate and the region anterior
to the cuspid is required to be left raw; this therefore heals by
secondary intention and subsequent fibrosis leads to gradual
relapse.9
Bilateral radical forearm flaps are hairy, and nearly half the
patients require a secondary debulking procedure. Facilities
for free tissue transfer are not universally available.10 Caniff
et al.11 recommended temporal myotomy or coronoidectomy
to release severe trismus caused by the atrophic changes in
the tendon of the temporalis muscle secondary to the disease.
If mouth-opening is still less than 35 mm after release of
fibrosis then there is pronounced peroperative improvement
in mouth opening after bilateral coronoidectomy.
Complications such as extraoral scarring on the face and
intraoral growth of hair were common observations when
extended nasolabial flaps were used for reconstruction of
defects. The patients’ compliance was not very good as far as
facial aesthetic were concerned in the nasolabial group. The
technique of platysma muscle flap is more demanding than
that of the extended nasolabial flap, and must be mastered
properly.
We recommend the use of the platysma muscle flap rather
than the extended nasolabial flap for reconstruction of intrao-
ral defects after release of oral submucous fibrosis, as facial
aesthetics are not compromised, and the risks of broadening
of the commissure and a pinched appearance of the lips are
avoided. As the incision is some way from the face, the scars
are hidden underneath collars, and the patients’ compliance
was good.
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