Long-term functional outcomes after total tongue reconstruction: Consideration of flap types, volume, and functional results

3D modeling of anterior 2/3rds glossectomy reconstruction: A volume based donor site evaluation

OBJECTIVE

Anterior 2/3rds glossectomy results in significant patient morbidity due to speech and swallowing impairment. Microvascular free flap reconstruction compensates for large volume defects. Flap volume is based on the adipose content of the donor site and varies by patient body mass index (BMI) and donor site location. We sought to correlate flap thickness at different donor sites with patient BMI to determine optimal donor site selection.

METHODS

Patients with CT scans of the oral cavity, thorax and lower extremity were identified and included. The volumes of the anterior 2/3rds of the tongue were measured and recorded using computed tomography-generated modeling. Pre-muscular tissue thicknesses at anterolateral thigh (ALT), deep inferior epigastric artery (DIEP), latissimus dorsi, and parascapular donor sites were measured. The donor site adequency was defined as reconstructing the tongue volume within 10% of the ideal volume required and stratified based on patient BMI.

RESULTS

In 144 patients, the average anterior 2/3rds glossectomy defect was 100.3 cm3. Glossectomy defect size was highly correlated with BMI (p < 0.001). The DIEP flap had the largest volume (155.4 cm3), followed by latissimus (105.6 cm3), parascapula (97.8 cm3), and ALT (60.5 cm3). For patients with BMI ≤ 30, the DIEP flap best reconstructed native tongue volume (up to 113 % of native tongue volume). In patients with BMI > 30.1, native tongue volumes were approximated by the latissimus flap (89-92 % of native tongue) and parascapular flap (85-95 % of native tongue volume). In BMI > 30.1 the DIEP flap provided excess tissue bulk (129-135 % of native tongue volume).

CONCLUSION

The DIEP flap more closely approximates the volume needed to reconstruct anterior two-thirds tongue defects for BMIs ≤ 30. The subscapular system flaps provided the best volume match for BMIs > 30 and the DIEP flap provided excess tissue bulk which could be adjusted in the reconstruction process.

The Anterolateral Thigh Flap in Head and Neck Reconstruction

The anterolateral thigh (ALT) free flap has become a workhorse for head and neck reconstruction. This paper offers a thorough introduction to the ALT flap, covering its anatomy, surgical technique, adaptable designs, and use in a range of clinical settings along with case studies. With its long vascular pedicle and tissue versatility, the ALT flap is well-suited for matching varied defects. Still, understanding possible anatomic variances and managing complications are critical to its success. With this paper as a comprehensive guidance, surgeons can apply the ALT flap for difficult head and neck reconstructions and achieve the best possible results.

Impact of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction: A systematic review and meta-analysis

BACKGROUND

Limited data exist regarding the effect of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction. However, an adequate free flap volume is an important predictor of functional and patient-reported outcomes in head and neck reconstruction.

METHODS

A systematic review of Medline, Embase, and the Cochrane Central Register of Controlled Trials was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. A total of 6710 abstracts were screened, and 36 full-text papers were reviewed. Nineteen studies met the inclusion criteria and were used to extract data for this analysis.

RESULTS

A meta-analysis of 14 two-arm studies comparing the impact of adjuvant radiotherapy versus no adjuvant radiotherapy was performed. The main analysis revealed that 6 months postoperatively, irradiated flaps showed a significant reduction of volume (average, 9.4%) compared to nonirradiated flaps. The average interpolated pooled flap volumes 6 months postoperatively were 76.4% in irradiated flaps and 81.8% in nonirradiated flaps. After a median postoperative follow-up of 12 months, the total flap volume was 62.6% for irradiated flaps and 76% for nonirradiated flaps. Four studies reported that chemotherapy had no significant impact on free flap volume.

CONCLUSIONS

Compared to nonirradiated flaps, irradiated flaps were significantly reduced in volume (range, 5% to 15.5%). Clinicians should take this into account when planning the surgical reconstruction of head and neck defects. Conducting large-scale prospective studies with standardized protocols and well-defined follow-up measurements could contribute to defining the ideal, personalized free flap volume for optimal function and patient-reported outcomes.

A novel flap design technique for subtotal tongue reconstruction with an "Individualized and Convenient Tongue Model"

BACKGROUND

To achieve improved functional outcomes in subtotal tongue reconstruction, a flap design with sufficient volume and appropriate shape is necessary. In this study, we introduce an "Individualized and Convenient Tongue Model" (ICTM) for flap design in subtotal tongue reconstruction.

METHODS

By studying the anatomical morphology of the tongue, we found a similar geometry within the dorsum and body of the tongue as well as the mouth floor. This can be used to create an ICTM through folding and splicing. We can simulate tongue defects in the ICTM and transform defect shapes into guide plates for flap design. In this study, fifty-eight patients requiring subtotal tongue reconstruction were randomly divided into two groups: an ICTM group (35 patients) and a conventional group (31 patients). In the ICTM group, we individually designed profunda artery perforator flaps (PAPFs) or anterolateral thigh flaps (ALTFs) using the ICTM method. In the conventional group, the flap was designed according to the surgeon's clinical experience. Patient demographics, operative and follow-up data were recorded. Swallowing, speech intelligibility, and cosmetic results were assessed using appropriate scales.

RESULTS

All flaps survived, although there were no significant differences in tumor size, operation time, flap size, and complication rate compared to the conventional group. Patients in the ICTM group had significantly improved speech intelligibility (p = 0.019), cosmetic appearance (p = 0.009), and swallowing ability (p = 0.003).

CONCLUSIONS

The ICTM technique is an effective and convenient solution for subtotal tongue reconstruction that provides an individualized flap design and improves functional outcomes compared to the conventional design.

Functional outcomes and complications of total glossectomy with laryngeal preservation and flap reconstruction: A systematic review and meta-analysis

OBJECTIVE

To analyze the functional outcomes and complications of total glossectomy with laryngeal preservation and reconstruction with free or pedicled flaps.

METHODS

A search was conducted using Pubmed/MEDLINE, Cochrane Library, Scopus, and Google Scholar databases. A single arm meta-analysis was performed for feeding tube dependence (FTD), tracheostomy dependence (TD), and speech intelligibility (SI) rates. Peri-operative sequels and complications were evaluated as secondary outcomes.

RESULTS

A total number of 642 patients (median age: 54.2 years; 95% CI 52.1-58) were included. Functional assessment was performed after a median of 12 months (n = 623/642; 95% CI 10.6-12). Overall, the cumulative FTD rate was 22.9% (n = 188/627; 95% CI 10.2-38.7), the TD rate was 7.3% (n = 95/549; 95% CI 1.9-15.8), and the SI was 91.1% (n = 314/409; 95% CI 80.7%-97.8). The cumulative complication rate was 33.1% (n = 592/642). Eighteen patients (n = 18/592; 3.0%) experienced a major fistula, while aspiration pneumonia occurred in 17 cases (n = 17/592; 2.8%).

CONCLUSIONS

Total glossectomy with laryngeal preservation and pedicled/free flaps reconstruction may guarantee good functional results and an acceptable quality of life. Further prospective studies are advised to define clinical guidelines about proper patients' and flaps' selection.

Swallowing analysis in hemi-tongue reconstruction using motor-innervated free flaps: A cine-magnetic resonance imaging study

BACKGROUND

This study aimed to explore the outcomes of motor-innervated free flaps in hemi-tongue reconstruction by assessing the tongue mobility through midsagittal images from cine-magnetic resonance imaging.

METHODS

In this retrospective study, 47 patients who underwent tongue reconstruction following hemi-glossectomy and 10 control subjects without any surgical history were included. Patients were classified into two groups: the motor and no-motor innervation group. Various spatial parameters related to tongue mobility that were acquired from midsagittal sections were compared during consecutive swallowing phases.

RESULTS

Overall, the motor group showed improved functional swallowing scale compared with the no-motor group. In case of tongue base resection, the motor group showed improved mobility of the tongue base during pharyngeal phase, whereas the no-motor group showed increased laryngeal elevation for compensatory movement.

CONCLUSION

The tongue reconstruction with motor-innervated free flaps may facilitate swallowing capacity in patients with a hemi-tongue defect combined with tongue base resection.

Use of the double-paddle anterolateral thigh flap for locally advanced tongue carcinoma requiring second site reconstruction

BACKGROUND

Advanced oral tongue carcinoma can present with extension beyond the oral cavity. Operative defects after resection may involve multiple anatomical sites and significantly impact speech and swallowing. Dependence on long-term enteral feeding is not uncommon for these patients. The anterolateral thigh (ALT) flap is one of the most reliable and flexible flaps used in the reconstruction of total and subtotal tongue defects. The double-paddle flap modification may be a more suitable option for complex oral tongue defects after advanced tumor ablation.

METHODS

Case series of 31 patients with oral tongue squamous cell carcinoma that were classified as stage IV. The age of patients ranged from 32 to 63 years. We designed the double-paddle ALT flaps to reconstruct the two-site surgical defects (tongue defect and pharynx or neck skin defect). Postoperative viability of the flap was checked by clinical observation. The last examination was performed at 3-months after the completion of adjuvant chemoradiotherapy. The functional capacity of our patients was evaluated by three physicians (Head and Neck Surgeon, Radiation Oncologist, and Physiatrist) using a Speech Intelligibility Score and the Functional Oral Intake Scale.

RESULTS

A total of 31 patients with surgical defects after total or subtotal tongue resection for cancer underwent double-paddle ALT flaps for reconstruction from March 2018 to December 2019. The dimension of flaps from 8 × 12 cm to 10 × 18 cm were divided into double-paddle from 8 × 5 cm to 10 × 10 cm. There was one case of pedicle thrombosis, one case of postoperative bleeding, three cases of neck infection, and six cases of salivary fistula. Our patients were seen in follow up from 6 to 36 months, with median follow-up of 23.5 months. The survival rate of ALT flap was 100%. All of our patients achieved an oral diet by 9 months after surgery. The mean score speech intelligibility was 2.74 ± 0.68 (4-point ordinal scale). The 2-year disease-free survival rate was 61.3%.

CONCLUSIONS

The double-paddle ALT flap is a reliable flap suitable for oral defects involving multiple subsites after ablative procedures. The majority of patients demonstrated acceptable functional rehabilitation.

CLINICAL QUESTION/ LEVEL OF EVIDENCE

Therapeutic, IV.

An alternative surgical technique for advanced tongue/tongue base cancer without free flap reconstruction

BACKGROUND/PURPOSE

Locally advanced tongue or tongue base cancer is recommended to be treated by radical resection that is usually detrimental to physiological functions. This study reports the efficacy and treatment outcome of the patients who had received total glossectomy and laryngeal suspension without lip-split mandibulotomy and free flap reconstruction to preserve laryngopharyngeal function.

METHODS

From 2010 to 2018, 37 consecutive patients who had received the surgery were retrospectively recruited.

RESULTS

The overall five-year survival is 72%. The postoperative dependent rate of feeding tube and tracheostomy largely decreases within 1-year follow-up. Treated by this surgical method, these patients are free from facial disfiguration, donor site morbidity, and destructive mastication and occlusion. It is also feasible to perform this surgical technique in the recurrent cases previously treated by chemoradiation.

CONCLUSION

Total glossectomy with laryngeal suspension can be successfully applied to locally advanced tongue or tongue base cancer, and benefits the patients with improved survival and preserved physiological function. Especially surgeons for free flap reconstruction are understaffed at some regional or district hospitals.

Magnitude of radial forearm free flaps and factors associated with loss of volume in oral cancer reconstructive surgery: Prospective study

BACKGROUND

Adequate flap volume is key to maintaining oral function after oral cancer surgery. This study aimed to evaluate changes in radial forearm free flap (RFFF) volumes after 1 year of follow-up following ablative tumor surgery in the head and neck.

METHODS

A prospective study that recorded the clinical data of 20 patients with head and neck cancer who underwent RFFF reconstruction. Magnetic resonance (MR) and Mimics Research 19.0 software were used to measure the RFFF volumes at 1, 3, 6, and 12 postoperative months.

RESULTS

Compared with one postoperative month, the RFFF volume decreased by 15.5%, 29.4%, and 42.0% at 3, 6, and 12 months, respectively, after surgery. A significant positive correlation between postoperative radiotherapy and RFFF volume changes was detected.

CONCLUSION

The volume of RFFF decreases with time. It is recommended to use overcorrection, with a 40% increase in RFFF volume, to reconstruct head and neck tumor-related defects.

Chimeric profunda artery perforator - gracilis flap: A computed tomographic angiography study and case report

BACKGROUND

The possibility of harvesting the profunda artery perforator (PAP) flap in a chimeric configuration together with the innervated gracilis muscle may be a good option for dynamic reconstruction following total glossectomies. In this paper, we present a retrospective radiological study, which evaluates the presence and characteristics of the anatomical variation of the chimeric PAP - gracilis flap.

METHODS

The study sample comprised 66 patients (132 legs), 38 men, and 28 women with an average age of 56 ± 2 years old, who underwent head and neck reconstruction with a free flap. Preoperative computed tomographic angiography (CTA) was used for morphologic analysis. We present a case report of a patient with a total glossectomy reconstructed with this flap.

RESULTS

A perforator in the PAP area joining with the main pedicle of the gracilis muscle was found in 38 legs (28.8%). Mean length of the pedicle from the profunda femoral artery to the point where the perforator in the PAP area and the pedicle of the gracilis joined was 3.0 ± 0.3 cm. Differences in the existence of this vascular configuration were not significant comparing groups by sex, BMI, height, side or source vessel. Motion of the new tongue was documented clinically and with electromyography. The patient achieved an intelligible speech and normal diet.

CONCLUSIONS

Preoperative evaluation is necessary to assess the existence of a perforator in the PAP area joining with the main pedicle of the gracilis muscle. This chimeric flap has been demonstrated useful for dynamic reconstruction of a patient with a total glossectomy.

Assessment of Chronological Volume Changes in Radial Forearm Free Flaps for Tongue Cancer

OBJECTIVE

The radial forearm free flap (RFFF) is a commonly used free flap for tongue cancer. Postoperative changes in the volume of free flap are known to influence the functional restoration of the resected tongue. This study aimed to estimate chronological volume changes in RFFFs for tongue cancer and to determine the clinical factors affecting these changes.

METHODS

Clinical data for 19 patients who underwent RFFF reconstruction for tongue cancer between May 2004 and September 2013 were retrospectively reviewed. The flap volume was measured 3, 6, 12, 24, and 36 months after surgery using CT and the Picture Archiving and Communication System software.

RESULTS

Relative to volumes at 3 months, median flap volumes decreased to 98.55, 70.16, 62.86, and 58.84% at 6, 12, 24, and 36 months, respectively. None of the evaluated parameters were correlated with volume changes.

CONCLUSIONS

Over time, the volume of RFFF in the tongue decreased. Considering this, free flap reconstruction should be carried out in tongue cancer surgery.

Tongue reconstruction: Rebuilding mobile three-dimensional structures from immobile two-dimensional substrates, a fresh cadaver study

OBJECTIVE

To determine the two-dimensional (2D) characteristics of flaps necessary to create three-dimensional (3D) tongue anatomy.

METHODS

Dissection of 11 fresh, nonpreserved human cadavers was performed. Six defects in each were created: total tongue, total oral tongue, hemiglossectomy, oral hemiglossectomy, total base of tongue, and hemi-base of tongue. The resections were debulked to create flat, 2D mucosal flaps. The dimensions and shapes of these flaps were determined.

RESULTS

Each specimen showed consistent dimensions and geometry between cadavers. The total tongue was pear-shaped, the total oral tongue was egg-shaped, the oral hemi-tongue was bullet-shaped, the hemi-tongue resembled a dagger, the total base of tongue was rectangular, and the hemi-base of tongue was hour-glass shaped.

CONCLUSION

Typical dimensions and shapes of common tongue defects were determined. It is conceivable that customizing reconstructive flaps based on these data will increase the accuracy of neo-tongue reconstruction, and thus, improve functional outcomes.

Functional outcomes and survival of patients with oral and oropharyngeal cancer after total glossectomy

INTRODUCTION

Cancer of the oral cavity and oropharynx presents aggressive behavior and its diagnosis is, in most cases, performed in advanced stages. Total glossectomy is a therapeutic option in locally advanced cancer, and the only one in the recurrent or residual disease, after chemoradiotherapy.

OBJECTIVE

To evaluate the clinical-epidemiological profile, postoperative complications, survival rates and functional aspects of patients with oral cavity and oropharynx cancer after total glossectomy.

METHODS

It was a retrospective study where 22 patients were included with oral cavity and oropharyngeal cancer after total glossectomy at the Hospital Regional do Vale do Paraíba, em Taubaté, São Paulo.

RESULTS

All patients were male, with a median age of 57 years, most of tumors are located in the tongue and floor of the mouth and classified as stage IVa. Total glossectomy as initial treatment was performed in 18 and as salvage in four patients. The major pectoralis myocutaneous flap was used for reconstruction in all cases. The main postoperative complication was wound infection and salivary fistula.

CONCLUSION

Overall survival was 19% and cancer-specific survival was 30.8% in five years. Eight patients were rehabilitated for exclusive oral feeding without the dependence tracheostomy and enteral tube, all with an overall survival greater than 15 months.

"Five-point eight-line" anatomic flap design for precise hemitongue reconstruction

BACKGROUND

Reconstruction of hemiglossectomy defects requires careful flap design to avoid adverse functional and aesthetic outcomes.

METHODS

Hemitongue specimens were obtained from minipigs to study the three-dimensional anatomy and to define anatomic landmarks for precise measurements of flap requirement. The concept developed in animal models was then applied to hemiglossectomy reconstruction in clinical practice. Sixty-one patients were randomly enrolled into the following two groups: a "five-point eight-line segment" (FIPELS) flap design group (28 patients) and a conventional group (33 patients). Functional and aesthetic outcomes were compared between the two groups.

RESULTS

All flaps designed with the FIPELS technique matched the hemiglossectomy defects without the need for flap trimming, thus reducing the operating time (P = .03). Swallowing functions, speech intelligibility, and aesthetic outcomes were superior in the FIPELS group than that in the conventional group (P < .05).

CONCLUSIONS

The FIPELS flap design for hemiglossectomy reconstruction yields improved functional and aesthetic outcomes compared to a conventional flap design.

Primary clear cell sarcoma of the tongue and surgical reconstruction: About a rare case report

Clear cell sarcomas (SCC), also called "soft-tissue melanoma", are rare and aggressive tumors that preferentially affect the lower limbs (tendons and fasciae) and which have also been described in head and neck localizations. Their clinical and immunohistochemical mimicry with melanoma makes it difficult to diagnose sarcomas. SCC treatment is mainly focused on large-scale resection surgery with adjuvant radiotherapy because of their low chemo-sensitivity and extreme lymphophilia. In case of head and neck localization, these treatments may lead to function and aesthetic sequelae thus requiring the use of modern techniques of reconstructive surgery. The authors describe the diagnosis, treatment and follow-up of large lingual SCC case using a DIEP free flap reconstruction according to an original technique developed in the department. Given the characteristics of patients with SCC (a high proportion of women between 20 and 40 years old) and its inherent qualities (low morbidity of the donor site, volume delivered and excellent plasticity), the fascio-cutaneous free flap type "DIEP" "taken according to the design of the" Cathedral triptych seems to be a viable choice among the range of reconstruction solutions.

Microvascular reconstruction two years after subtotal glossectomy: Is it worth it?

We ought to report an unusual case of a 49-year-old patient who underwent delayed reconstruction of the oral cavity defect, with an anterolateral thigh flap, two years after surgical demolition and adjuvant chemo-radiotherapy. At the end of oncologic treatment, he could not eat through oral route and presented evident speech articulation difficulties. After surgical reconstruction, swallowing assessment showed an improvement of swallowing with no gross signs of airways inhalation. His understandability of speech improved as well. Delayed reconstruction by a microvascular free flap with exclusive functional rehabilitation intent is feasible and may have satisfactory functional outcomes.

The Very First Changes in the Tongue with the Development of Cancer

We describe the case of an elderly man with a 3-month history of pain at the tip of his tongue due to a lingual cancer. The lesion appeared slightly depressed and reddish. Our images show the very first changes in the tongue with the development of cancer. Patients with tongue pain often visit the internal medicine department first, so highlighting this case will help physicians detect lingual cancer quickly.