Correlation of Neotongue Volume Changes With Functional Outcomes After Long-Term Follow-Up of Total Glossectomy

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.

Preoperative sleep-disordered breathing and craniofacial abnormalities are risk factors for postoperative sleep-disordered breathing in patients undergoing skin-flap oropharyngeal reconstruction surgery for oral cavity cancer: a prospective case-control study

PURPOSE

After oropharyngeal reconstruction surgery, excessive flap volume within the oral cavity may increase the risk of pharyngeal obstruction during sleep. This prospective observational study aimed to test a hypothesis that the skin-flap oropharyngeal reconstructive surgery increases nocturnal apnea-hypopnea index (nAHI, primary variable) after surgery.

METHODS

Adult patients undergoing oropharyngeal reconstruction surgery participated in this study. The hypothesis was tested by comparing the results of portable type 4 sleep study and craniofacial assessments with lateral head and neck computed tomography scout image before and after surgery. Multiple linear regression analyses were performed to identify predictors for nAHI increase after the surgery.

RESULTS

In 15 patients, a postoperative sleep study was performed at 41 (27, 59) (median (IQR)) days after the surgery. nAHI did not increase after the surgery (mean (95% CI), 13.0 (7.2 to 18.7) to 18.4 (10.2 to 26.6) events.hour-1, p = 0.277), while apnea index significantly increased after the surgery (p = 0.026). Use of the pedicle flap for the oropharyngeal reconstruction (p = 0.051), small mandible (p = 0.008), longer lower face (0.005), and larger tongue size (p = 0.008) were independent predictors for worsening of nAHI after surgery. Hospital stay was significantly longer in patients with the pedicle flap (n = 8) than in those with the free flap (n = 7) (p = 0.014), and the period of hospital stay was directly associated with increase of nAHI after surgery (r = 0.788, p < 0.001, n = 15).

CONCLUSIONS

Oropharyngeal reconstruction surgery worsens sleep-disordered breathing in some patients with craniofacial and surgical risk factors.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (UMIN000036260, March 22, 2019), https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000036260.

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.

Favourable swallowing outcomes after subtotal glossectomy with laryngeal suspension

Subtotal or total glossectomy for advanced tongue cancer has an adverse impact on swallowing. The purpose of this retrospective study was to analyse postoperative swallowing outcomes and to determine the ideal reconstruction method in these patients. The clinical and swallowing data of patients with tongue cancer who underwent subtotal glossectomy at the study institution between 2005 and 2019 were reviewed retrospectively. Data were available for 101 patients. The most common reconstruction method was a free rectus abdominis musculocutaneous flap (69 cases). The postoperative feeding tube dependency rate was 11.1% at discharge and 9.4% at 1 year. During the study period, laryngeal suspension and/or a cricopharyngeal myotomy was performed in 39 patients (38.6%), with 25 of these operations performed after 2017. Patients treated in 2017-2019 were significantly more able to take thin liquid (P < 0.001) and lost less weight (P = 0.015) compared to those treated in 2005-2016. Multivariate analysis of 61 patients who did not undergo laryngeal suspension and/or cricopharyngeal myotomy showed significant feeding tube dependency in those aged 65 years and older (P = 0.004). Thin liquid intake was significantly improved after subtotal glossectomy with laryngeal suspension, which led to better postoperative swallowing and improved quality of life.

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap

OBJECTIVE

Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation.

METHODS

Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded.

RESULTS

The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function.

CONCLUSIONS

Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

Effects of maxillofacial prosthetic treatment on oral health-related quality of life and masticatory ability of patients with head and neck tumors

PURPOSE

Using multivariate analysis, this study investigated the effectiveness of maxillofacial prosthetic treatment in relation to oral health-related quality of life (OHR-QoL), masticatory ability (food intake status score and gum-jelly test score) and related factors in patients who had undergone surgery for head and neck tumors.

METHODS

The study cohort comprised 112 patients who underwent surgical resection and prosthetic treatment among 224 patients with head and neck tumors seen at the Maxillofacial Prosthetics Clinic of Tohoku University Hospital in a 2-year period. Correlations between OHR-QoL, food intake status score, and gum-jelly test score (criterion variables), and age, sex, maxillary defect, tongue/soft tissue defect, reconstructive surgery, and chemoradiotherapy (explanatory variables) were investigated, and the data were examined statistically.

RESULTS

Maxillary defect, tongue and soft palate tissue defect, and chemoradiotherapy were identified as factors that hindered the effectiveness of maxillofacial prosthetic treatment for improvement of the OHR-QoL, food intake status score, and gum-jelly test score. On the other hand, reconstructive surgery was a factor that facilitated the improvement of OHR-QoL and masticatory ability with maxillofacial prosthetic treatment.

CONCLUSION

The factors identified to be related to the success or failure of maxillofacial prosthetic treatment suggest the importance of combining prosthetic intervention with surgical reconstruction.

Three-Dimensional Analysis of Flap Volume Change in Total Tongue Reconstruction: Focus on Reinnervated Dynamic Tongue Reconstruction

In general, flap volume decreases over time and further in the case of a denervated muscle flap. In our institution, dynamic reconstruction, including functional muscle flaps, has been used to aid functional recovery in the past 6 years. This study aimed to determine the effect of volume change of the fat and muscular sections of reconstructed tongue flaps after motor nerve reinnervation in dynamic total tongue reconstruction using 3-dimensional measurement and analysis. A retrospective chart review was performed on 21 patients who underwent total tongue reconstruction using an anterolateral thigh free flap from 2015 to 2020. The fat and muscle volumes of the flap were measured using computed tomography data obtained before surgery (T0), 2 weeks after surgery (T1), and 6 months after surgery (T2) using a 3-dimensional rendering software. Among the 21 patients that underwent tongue reconstruction, 10 underwent dynamic reconstruction, whereas 11 underwent conventional reconstruction using a fasciocutaneous flap. T2 volume compared with T1 was 69.08% in the conventional reconstruction group, and the fat and muscle portions in the dynamic reconstruction group were 77.04% and 69.06%, respectively. No significant difference was noted in the volume change between the 2 groups. After dynamic tongue reconstruction, the muscular volume of the flap had similar volume reduction rate as the fat volume. The dynamic reconstruction was effective not only for functional muscle transfer but also for maintaining the volume of the reconstructed muscle flap.

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.

Free flap volume changes: can we predict ideal flap size and future volume loss?

PURPOSE OF REVIEW

Under anticipating free flap volume may lead to deficits in functional and aesthetic outcomes. Alternatively, over anticipating may compromise airway patency, lead to prolonged tracheostomy dependence or poor oral intake, and cause poor cosmetic outcomes. Surgeons face a fine balance in creating a functional reconstruction that accounts adequately for volume changes in the future.

RECENT FINDINGS

Recent studies are elucidating the complex and multifactorial volume changes of free flaps that are dependent on postoperative radiation, flap composition, weight fluctuations, and site of reconstruction. Radial forearm free flaps typically lose about 40% of their volume, regardless of patient-dependent variables. Muscle flaps exhibit significant fluctuations with patient-dependent variables. Adipose-prevalent flaps are likely more resistant to radiation effects but are more dependent on postoperative weight changes in the patient.

SUMMARY

Free flap volume over anticipation recommendations range from 1.1 to 1.4 times the final volume to account for future atrophy but patient characteristics including postoperative radiation, anticipated weight loss, and flap composition should be incorporated into intraoperative decisions for final flap volume.

Evaluation of Tongue Functions After Free Flap Reconstruction

Squamous cell carcinoma of the tongue is the most common malignancy of the oral cavity, the lateral border being the commonest site. The treatment strategies mandate surgery followed by appropriate reconstruction as the first line of management. There are many suitable methods of reconstruction of tongue defects after surgery, but the principle of an ideal reconstruction method should provide not only satisfactory structural cosmesis, but also good restoration of function. We present our experience with the skin lined free flaps reconstruction for defects of the tongue and floor of mouth, and present analyses of the functional outcomes of reconstruction. This prospective longitudinal study included 93 patients and was conducted in a tertiary care center in Punjab. All patients underwent free flap reconstruction after tumor removal. The functional outcome of the tongue following reconstruction was evaluated 9 months after the completion of treatment. Functions were assessed and matched with sexes and age-matched normal individuals. The data obtained were analyzed by the student 't' test and the p values < 0.05 were considered statistically significant. The duration of swallowing in patients with FRF flap and ALT flap when compared to the normative was significant (< 0.05). There were changes in configuration and volume of the oral cavity after surgery which generates resonant and articulatory alterations, thus the intelligibility of the patient's speech is lowered. There is also a restriction in the tongue movements and reduction in the sensations of the reconstructed part of the tongue. Both the free ALT flap and the FRF flap can provide acceptable functional restoration of the tongue after radical tumor resection.

Current status and evolution of microsurgical tongue reconstructions, part I

Reconstructive surgery in the management of head and neck cancer has evolved to include structure-specific approaches in which organ-specific treatment algorithms help optimize outcomes. Tongue cancer management and reconstruction are surgical challenges for which well-executed reconstructive plans should be completed promptly to avoid delaying any subsequently planned oncologic treatment. Crucial considerations in tongue cancer resection are the significant functional morbidity associated with surgical defects, particularly in terms of speech and swallowing, and the consequent negative impact on patients’ quality of life. With the evolution of microsurgical techniques and the development of the perforator flap concept, flap options can be tailored to the characteristics of various tongue defects. This has allowed the implementation of pliable flaps that can help restore tongue mobility and yield subsequent functional outcomes. Using an evolutional framework, we present this series of reviews related to tongue reconstruction. The first part of the review summarizes flap options and flap-related factors, such as volume and tissue characteristics. Related functional aspects are also presented, including tongue mobility, speech, and swallowing, as well as ways to evaluate and optimize these outcomes.

Comparison of functional and survival outcomes in pedicled and microsurgical flap reconstruction for near-total and total glossectomies

Introduction:

Patients with advanced carcinoma tongue end up with near-total/total glossectomy (NTG/TG). We intended to compare functional, oncological, and survival outcomes of patients undergoing pedicled and microsurgical flap reconstruction in NTG/TG patients at our hospital.

Methodology:

A prospective study was conducted for 7 years on 91 patients with carcinoma tongue who underwent NTG/TG at our institute. Patients underwent anterolateral thigh (ALT), free radial artery forearm flap (FRAFF), and pectoralis major myocutaneous (PMMC) flap reconstruction and were followed up for immediate complications and functional outcomes for speech, swallowing, and decannulation after completion of adjuvant treatment and then for survival rates for a period of 60 months and statistically analysed with log rank test and Fisher’s exact test for correlation.

Results:

Ninety-one (42.85%) patients underwent NTG, while 57.14% underwent TG. 85% of patients had >5 mm margin, 14% had ≤ of 5 mm, and none were positive. 57% of patients did not have postoperative complications and 10% underwent re-exploration. During follow-up, 85.7% of patients were able to take orally: 52% soft diet and 32% liquid diet. Multivariate analysis of individual flaps, swallowing, and speech intelligibility values were significant. After 5 years of postadjuvant therapy, there was 76% overall survival, 11% local recurrence and 12% had regional recurrence.

Discussion:

Morbidity and functional outcome depends on the extent of resection. PMMC flaps can be done on lack of expertise. FRAFF has better functional outcomes owing to pliability of flap. ALT and other bulky flaps require expertise and are prone to flap-related complications. Planning of reconstruction should be based on the defect size together with counseling of patients regarding the risk of complications and delay in adjuvant therapy.

Results of sequential swallowing assessments in patients undergoing upfront surgery for oral tongue squamous cell carcinoma

BACKGROUND

The swallowing outcomes in patients undergoing glossectomy have been inconsistently reported in the literature owing to variable follow up times, different tools for assessment and lack of single institution large scale studies. The aim of our study was to assess the patterns of swallowing outcomes over time and identify factors affecting nasogastric tube dependency at 1-year post-surgery.

MATERIALS AND METHODS

This was a retrospective study of treatment naïve patients with oral tongue carcinoma who underwent surgery and attended the speech and swallow clinic between January 2016 and December 2019 at our institute were included in the study. The findings of swallowing assessment by a speech language pathologist at three time points were recorded.

RESULTS

A total of 606 patients were found eligible for the study. The median age of the patients was 50 years with the 211 (34.8%) patients having T3/T4 disease. The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time with an increasing number of patients switching over to a solid diet by 1 year. A higher defect class (HR = 24.43 [3.48-171.27]) and presence of co-morbidities (HR = 4.17 [1.59-10.92]) were associated with sustained feeding tube dependency status at 1 year. A nomogram was developed based on these findings.

CONCLUSION

The swallowing outcomes in terms of tube dependence and the spectrum of diet tolerance seem to improve over time. A higher defect class and presence of co-morbidities were associated with NGT dependency at 1 year.

The Functional & Quality of Life Outcomes of Total Glossectomy with Laryngeal Preservation

BACKGROUND

The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP).

OBJECTIVE

To examine prospectively collected objective, self-reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction.

METHODS

Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre- and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI).

RESULTS

All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P < .001) scores. There was no significant reduction in SHI or total MDADI scores. All patients maintained their QOL in the post-treatment time frame. There was no relationship between free-flap type and outcome.

CONCLUSION

Total glossectomy with laryngeal sparing and free flap reconstruction results in significant reduction in objective functional measurements, but patients report stable functional and quality of life outcomes after treatment.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects

OBJECTIVES

Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient.

METHODS

Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination.

RESULTS

Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R² = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (β = 0.01, P = .003) and RF (β = -0.01, P = .009) were individual predictors of flap volume loss.

CONCLUSIONS

Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

A Novel Laryngeal Preservation Technique following Total Glossectomy with Hyoid Bone Resection

Despite the recent progress of chemotherapy and sophisticated radiotherapy, surgery still remains the most reliable treatment for advanced tongue cancers in terms of survival. The major disadvantage of this treatment is that it should sacrifice the quality of patients' life. When the tongue cancer is so advanced as to involve the hyoid bone, which is considered a functional part of the larynx, radical operation needs to resect both the entire tongue and the larynx and the hyoid bone en bloc to prevent aspiration pneumonia. As a result of total laryngectomy, the patients will suffer significant disabilities: aphonia and the loss of deglutition that limits the oral intake to only liquid or pasty food. With this clinical background, we have been contriving to overcome these significant surgical shortcomings by conducting larynx-preserving operation. In this case report, we present our newly devised surgical method which consists of free-flap transfer with a combination of laryngeal suspension and a novel reconstructive technique, that is, epiglottis suspension, which enabled favorable swallowing function without aspiration and allowed a sufficiently wide airway for breathing. The operation worked quite successfully for the patient's quality of life. We believe this novel surgical method would serve as a larynx-preservation treatment for locally advanced tongue cancers with hyoid bone invasion.

Phonologic and Acoustic Analysis of Speech Following Glossectomy and the Effect of Rehabilitation on Speech Outcomes

PURPOSE

Changes in acoustic features in the perioperative phase for elucidating the mechanisms of articulation disorder and the effect of perioperative rehabilitation were studied prospectively.

MATERIALS AND METHODS

Sixty-two patients with 62 tongue cancer were divided into a partial glossectomy group (n = 40) and a reconstruction group (n = 22). Acoustic characteristics were analyzed during the preoperative and postoperative periods and after rehabilitation using the first and second formants of the vowels /a/, /i/, and /u/; the triangular vowel space area (tVSA); and the slopes of formant transitions.

RESULTS

In the 2 groups, decreases in the tVSA and formant slopes were found from the preoperative to the postoperative period, and the acoustic characteristics of the reconstruction group especially improved to preoperative values after rehabilitation. Analysis of the postoperative period showed that acoustic characteristics were altered at the site of surgical resection.

CONCLUSION

Changes of acoustic variables are related to excision size and site, suggesting the distinctive tongue portion for the articulation of each speech sound. Perioperative rehabilitation could activate the articulators and increase the range of movement of the remaining tongue, especially the preserved anterior tongue.

The anterolateral thigh fold-over flap for total and subtotal glossectomy reconstruction

BACKGROUND

We present a fold-over technique for total and subtotal glossectomy reconstruction utilizing the ALT flap with the goal of increasing soft tissue bulk.

METHODS

Retrospective review of total and subtotal glossectomy patients undergoing ALT fold-over flap reconstruction from January 2007 to December 2012.

RESULTS

Eight patients fit inclusion criteria. Average length of follow-up was 35 months. There were no flap failures. At last follow-up, no patients were tracheostomy dependent. Six out of 8 patients (75%) did not require a g-tube and were able to maintain their weight. Speech intelligibility was good in 6/8 patients (75%).

CONCLUSIONS

The ALT fold-over flap technique provides sufficient bulk to allow decannulation and airway protection as well as PO intake in most patients. Given the minimal donor site morbidity, it is our technique of choice for total and subtotal glossectomy defects. © 2016 Wiley Periodicals, Inc. Microsurgery 36:297-302, 2016.

Individual design of the anterolateral thigh flap for functional reconstruction after hemiglossectomy: experience with 238 patients

The aim of this study was to evaluate tongue function in patients with oral cancer treated surgically and reconstructed with anterolateral thigh free flaps (ALTFs). Patients (N=238) underwent primary reconstruction after hemiglossectomy between September 2012 and October 2014. Patients were divided into two groups according to the flap design: 'individual design' (ABC flap) and 'common design'. Patients were followed postoperatively and assessed after 6 months for the following functional outcomes: speech, deglutition, tongue mobility, and donor site morbidity. Intelligibility and deglutition were each scored by an independent investigator. Data were analyzed using SPSS version 16.0 software. No differences in mean speech intelligibility scores were observed between the two groups (good: P=0.908; acceptable: P=0.881). However, the ABC flap offered recovery advantages for swallowing capacity compared to the common design flap (MTF classification good: P=0.028; acceptable: P=0.001). The individualized ABC flap not only provides volume but also preserves mobility, speech intelligibility, and swallowing capacity. ALTFs require further improvement for the individualized functional reconstruction of the tongue after hemiglossectomy, but this work lays the foundation for these improvements.

Impact of body mass index, gender, and smoking on thickness of free soft tissue flaps used for orofacial reconstruction

Donor-site selection may play an important role in the reconstruction of large orofacial defects. The thickness and structure of transplanted tissue has to fit those of the recipient site to achieve a satisfactory outcome. To evaluate the thickness of free flaps that are frequently used for orofacial reconstruction and its association with body mass index (BMI), gender, and smoking, a prospective study was conducted. A total of 122 volunteers were included in the study, and their data regarding BMI, gender, and tobacco use were documented. Ultrasonography was used to evaluate the thickness of the radial and ulnar forearm flaps (RFFF and UFFF, respectively), the scapular and parascapular flaps (SF and PSF, respectively), the anterolateral thigh flap (ALT), and the free fibular flap (FF). Correlation and regression analysis were performed to assess any relationship among parameters and to investigate their effect on flap thickness. The UFFF showed the lowest thickness (0.65 ± 0.16 cm), followed by the RFFF (0.83 ± 0.20 cm). The FF showed a comparable thickness (0.82 ± 0.26 cm), followed by the SF (0.99 ± 0.13 cm) and the PSF (1 ± 0.14 cm). The ALT flap displayed the greatest thickness (1.42 ± 0.42 cm) and correlated especially with BMI and gender, whereas the UFFF was the thinnest with relatively constant values, regardless of potential influential factors.

Total glossectomy without laryngectomy - a review of functional outcomes and reconstructive principles

PURPOSE OF REVIEW

To provide an overview of functional outcomes and reconstructive principles of total glossectomy without laryngectomy reported in recent series, and the evidence regarding which patients are at risk for poor functional outcomes.

RECENT FINDINGS

After total glossectomy with laryngeal preservation gastric tube dependency ranges from 30 to 44% for primary treatment. Between 85 and 95% of patients are able to have their tracheostomy tube removed. Many patients can also regain meaningfully intelligible speech. In the setting of prior radiation or chemoradiation therapy, achieving oral diet and tracheostomy decannulation is less likely.Reconstructions must have sufficient bulk to allow for contact with the palate, and achievement of this vertical height has been shown to be associated with improved speech and swallowing outcomes. Laryngeal suspension is an important adjunct to prevent both laryngeal prolapse and minimize aspiration risk. The role of either sensory or motor reinnervation is unclear, although there is currently more evidence for the benefit of sensory reinnervation.

SUMMARY

With meticulous reconstructive technique and appropriate patient selection, total glossectomy with laryngeal preservation can be performed as a primary or salvage procedure with acceptable functional outcomes.

Comprehensive analysis of functional outcomes and survival after microvascular reconstruction of glossectomy defects

BACKGROUND

Few studies on tongue reconstruction provide a comprehensive, multidisciplinary analysis examining defect size, flap selection, function, and long-term survival. This report presents the largest study in the literature evaluating free flap reconstruction after glossectomy.

METHODS

A retrospective review of patients undergoing free flap glossectomy reconstruction from 2000 to 2012 was performed.

RESULTS

In this review, 268 patients were identified. Resections involving the tongue only included 59 partial glossectomies, 86 hemiglossectomies, 28 subtotal glossectomies, and 24 total glossectomies. Glossectomies performed with mandibulectomies were analyzed independently for speech and swallowing function (32 partial glossectomies, 18 hemiglossectomies, 8 subtotal glossectomies, and 13 total glossectomies with mandibulectomy). A total of 299 free flaps were performed, with 30 patients receiving two free flaps. Multivariate analysis demonstrating smoking (p = 0.018), composite resections (p < 0.001), and larger resections (total and subtotal glossectomies; p < 0.001) were associated with significantly worse speech results. Advanced age (p = 0.002), radiation (p = 0.003), and larger or composite resections had significantly worse swallowing function (p < 0.001). Patients with a persistent tracheostomy had significantly worse speech and swallowing function (p < 0.001), whereas innervated flaps were associated with superior speech (p = 0.049) and better swallowing function (p = 0.004). The surgical complication rate was 23.5 %, with only one total flap loss. Tumor stage (p = 0.003), positive margins (p < 0.001), lymphovascular invasion (p = 0.023), and chemotherapy (p < 0.001) were associated with significantly worse overall survival. The median overall survival time was 50.5 months (range 39-79 months).

CONCLUSIONS

Although comorbidities and the extent of resection impair both speech and swallowing, reconstruction, particularly with innervated free flaps, still affords the majority of patients' reasonable function.

Palatal Mucoperiosteal Island Flaps for Palate Reconstruction

Background

Many options are available to cover a palatal defect, including local or free flaps. The objective of this study was to evaluate the usefulness of palatal mucoperiosteal island flap in covering a palatal defect after tumor excision.

Methods

Between October 2006 and July 2013, we identified 19 patients who underwent palatal reconstruction using a palatal mucoperiosteal island flap after tumor excision. All cases were retrospectively analyzed by defect location, size, tumor pathology, type of reconstruction, and functional outcomes. Speech and swallowing functions were evaluated using a 7-point visual analog scale (VAS) score.

Results

Among the 19 patients, there were 7 men and 12 women with an age range of 25 to 74 years (mean, 52.5±14.3 years). The size of flaps was 2-16 cm² (mean, 9.4±4.2 cm²). Either unilateral or bilateral palatal island flaps were used depending on the size of defect. During the follow-up period (mean, 32.7±21.4 months), four patients developed a temporary oronasal fistula, which healed without subsequent operative. The donor sites were well re-epithelized. Speech and swallowing function scores were 6.63±0.5 and 6.58±0.69 on the 7-point VAS, indicating the ability to eat solid foods and communicate verbally without significant disability.

Conclusion

The palatal mucoperiosteal island flap is a good reconstruction modality for palatal defects if used under appropriate indications. The complication rates and donor site morbidity are low, with good functional outcomes.

Functional tongue reconstruction with the anterolateral thigh flap

BACKGROUND

A retrospective study was conducted to evaluate the advantages of anterolateral thigh (ALT) flap in tongue reconstruction.

METHOD

From September 2008 to February 2012, patients receiving ALT flap tongue reconstruction were included in the study. Patients undergoing ALT flap were compared with those undergoing similar surgery with radial forearm flap (RFF). The medical records of the included patients were reviewed, and a questionnaire was used to assess acceptability of the surgery.

RESULTS

All flaps (both ALT and RFF) were successful In the ALT group, most patients were satisfied with the appearance of the reconstructed tongue and the intelligibility of their speech, and there were fewer complications with this technique compared with the RFF.

CONCLUSION

The ALT flap is an ideal method for tongue reconstruction. The thickness and volume of the ALT flap can be adjusted based on the individual extent of the defect, and it can not only provide bulk but also ensure mobility, and it has other advantages also, including a long pedicle and low donor site morbidity.

Functional assessment and rehabilitation: how to maximize outcomes

The number of oral cavity and oropharyngeal cancer survivors is rising. By 2030, oropharyngeal cancers are projected to account for almost half of all head and neck cancers. Normal speech, swallowing, and respiration can be disrupted by adverse effects of tumor and cancer therapy. This review summarizes clinically distinct functional outcomes of patients with oral cavity and oropharyngeal cancers, methods of pretreatment functional assessments, strategies to reduce or prevent functional complications, and posttreatment rehabilitation considerations.

Flap selection and functional outcomes in total glossectomy with laryngeal preservation

OBJECTIVE

Reconstruction of total glossectomy defects has been revolutionized by the popularity of free flap use in the head and neck. Challenging defects can be addressed with a variety of different free and pedicled flaps. The purpose of this study is to review our method of flap selection in cases of total glossectomy defects with laryngeal preservation, with an emphasis on the variations of these defects and patient body habitus.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care referral center.

SUBJECTS AND METHODS

All patients undergoing total glossectomy with laryngeal preservation (TGLP) by the senior author (YD) from September 1997 to May 2012. Objective data regarding patient demographics, existing defect, method of reconstruction, adjuvant treatment, operative details, outcomes, and complications were recorded. Both means and frequency of prolonged tracheostomy or gastrostomy tube were used to assess outcomes.

RESULTS

One hundred and three patients were identified. Ninety-four met inclusion criteria. All patients were T3 or T4 stage tumors. Mean follow-up was 3.4 years. Fifty-nine patients (62%) underwent free flap reconstruction while the remaining 35 (37%) were treated with a pedicled pectoralis myocutaneous flap. Tracheostomy decannulation and gastrostomy tube removal rates were 84% and 29%, respectively. No patients were converted to total laryngectomy.

CONCLUSION

Optimal reconstruction of TGLP defects may be accomplished with either pedicled or free-tissue flap reconstruction. Selecting an ideal flap for reconstruction of total glossectomy defects should be patient specific and based on matching donor flap bulk. This treatment approach demonstrates high tracheostomy and gastric tube independence.