Oral Submucous Fibrosis – partial Trismus Mouth Opening Surgery With Nasolabial Flap Surgery

The growth of aesthetic surgery in India

Cosmetic surgery or plastic surgery in India has become highly sought after since the advent of globalization. Some of the common procedures performed include brow lift eyelid surgery, face lifts, correction of congenital defects, reconstructive surgery for trauma victims etc. There has been a mushrooming of plastic surgery hospitals in India of late. Patients who wish to opt for cosmetic procedures have to be very cautious in choosing the right hospital.

There have been many instances where the results of the surgery have been catastrophic for the patient. This necessitates corrective surgery at the hands of an experienced surgeon. Therefore, patients have to be very cautious in the selection of the surgeon as well as the hospital.

Young man with progressively worsening mouth opening

The patient is a 19-year-old male from Kashipur in Manipur, India who began noticing a tightness while opening his mouth from around two years ago. This was slowly getting worse with the passage of time. It has now reached a point where he is able to opening his mouth by only around 7 mm. This has made eating very difficult and he noticed that his cheeks had also started hardening. The patient has been chewing khaini, a mixture of tobacco, lime and betel nut since he was 12 years old. He however does not smoke cigarettes or drink alcohol.

Patient decides to seek medical attention for his mouth opening problems

It ultimately reached the point that the patient decided to seek medical attention for his problem. An oral and maxillofacial surgeon in his hometown examined him and informed him that he had submucous fibrosis. He also informed the patient that this had been brought about by his tobacco habit and advised the patient to quit his habit immediately. The patient was also informed that treatment for submucous fibrosis was mainly surgical and that only a few specialty hospitals in India performed this surgery. He then referred the patient to our hospital for management of his submucous fibrosis as our hospital is renowned for oral submucous fibrosis surgery. Our hospital is also renowned for a variety of facial cosmetic surgery in India.

What is oral submucous fibrosis?

Oral submucous fibrosis is a chronic, complex, premalignant (1% transformation risk) condition of the oral cavity, characterized by progressive fibrosis of the submucosal tissues. As the disease progresses, the jaws become rigid to the point that the person is unable to open the mouth. The condition is remotely linked to oral cancers and is associated with areca nut or betel quid chewing. This is a habit that is practiced predominantly in SouthEast Asia and India and is similar to tobacco chewing. Once oral submucosal fibrosis has set in, it cannot be reversed and treatment mainly consists of management with steroids and surgery.

Initial presentation at our hospital for management of oral submucous fibrosis

Dr SM Balaji, oral submucous fibrosis surgeon, examined the patient. Various measurements were obtained from the patient’s mouth. The patient had a mouth opening of about 7mm. Clinical examination revealed thick fibrous bands on the buccal mucosa bilaterally. He was diagnosed with oral submucous fibrosis. The patient’s condition was explained to him in detail. Surgical planning to for excising the fibrous bands followed by covering the raw area with nasolabial flap was also discussed with the patient. The patient was in agreement with the treatment plan and signed the consent form.

Surgical treatment of the patient’s oral submucous fibrosis

The patient underwent awake bronchoscopic intubation as the patient was not able to open his mouth adequately for normal intubation. Following successful intubation, the incisions were marked out on the skin along natural skin creases to minimize visible scar formation. Following this, a linear horizontal incision was made in the buccal mucosa bilaterally and the fibrous bands were excised. This was followed by placement of an elliptical incision in the nasolabial region bilaterally and an inferiorly based nasolabial flap was elevated.

Blood supply to the flap was through the facial artery. Care was taken at all times to ensure that blood supply was not compromised. Tunneling was then done and the flap was rotated Intraorally and sutured to the buccal mucosa using resorbable sutures. A mouth opening of about 3.2 cm was achieved through this procedure.

Successful outcome to the surgical intervention

The outcome of the surgery was as planned. Adequate mouth opening was achieved postsurgically. The patient was advised to do mouth opening exercises to further improve his mouth opening. There was hardly any noticeable scar on the nasolabial region at the patient’s one month follow up appointment.

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