Functional tongue reconstruction with the anterolateral thigh flap

The application of mixed reality technique in oromaxillo-facial reconstruction with the perforator flap for malignant tumor patients

Objectives

The integration of quantitative imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) with mixed reality (MR) technology holds promise for enhancing the diagnosis, prognosis, and treatment monitoring of cancer. This study compares the characteristics and effects of MR and color Doppler ultrasound (CDU) in the localization of perforator blood vessels in the lower extremities.

Methods

Two techniques were used to locate the perforator vessels in 40 cases of maxillofacial defect repair using perforator flaps from the lower extremities. The number of perforator vessels located in the flap area and the actual number of perforator vessels explored during the surgery were recorded. The recognition rate was calculated and the operation time and blood loss were recorded for each case.

Results

The recognition rates of MR technology and CDU in perforating vessels of the lower limbs were 93.9% and 97.2%, respectively (p > 0.05). The operation time was 52-74 minutes, 65-88 minutes (p > 0.05). The average bleeding volumes were 24 and 56 ml (p < 0.05), respectively. All perforator flaps were alive. One flap had a crisis and recovered after emergency exploratory treatment. Thirty donor sites of the lower extremities were directly sutured, and wounds were closed by abdominal skin grafting in 10 cases.

Conclusion

MR technology for successfully identifying perforator vessels can shorten the operation time, reduce the amount of bleeding in the donor site, and reduce trauma to the donor site.

Volumetric changes in post hemiglossectomy reconstruction with anterolateral thigh free flap versus radial forearm free flap

The volume of the reconstructed tongue is considered a critical factor for tongue function. Studies investigating the difference in volume loss between the anterolateral thigh free flap (ALTF) and radial forearm free flap (RFFF) used in reconstruction of the tongue after hemiglossectomy are lacking. The aim of this study was to determine whether there is a significant difference in shrinkage between these two flaps. This was a retrospective study of all patients treated for tongue cancer by hemiglossectomy who underwent either ALTF or RFFF reconstruction at the University of Florida College of Medicine between January 2018 and April 2022. Computed tomography scans were used to measure the volumetric changes in the ALTF and RFFF at two time points over a 6-month period. Of the 85 patients assessed, 10 fulfilled the inclusion criteria: five were reconstructed with an ALTF and five with a RFFF. All underwent adjuvant radiotherapy. The mean ALTF percentage shrinkage was 39.6% ± 3.9%, while for the RFFF it was 51.1% ± 6.2% (P = 0.008). Therefore, it is recommended that the difference in volume loss between the two flaps is taken into consideration. It is suggested that in hemiglossectomy cases, the ALTF is made 1.4 times larger than the defect, while the RFFF is made 1.5 times larger.

Development and growth of median structures in the human tongue: A histological study using human fetuses and adult cadavers

Glossectomy is a surgical procedure performed to remove all or part of the tongue in patients with cancer. The removal of a significant part of the tongue has a marked effect on speech and swallowing function, as patients may lose not only the tongue muscles but also the median lingual septum (MLS). Therefore, to achieve successful tongue regeneration, it is necessary to investigate the developmental processes of not only the tongue muscles but also the MLS. This study was conducted to clarify the mutual development of the tongue muscles and the MLS in human fetuses. Serial or semi-serial histological sections from 37 embryos and fetuses (aged 5-39 weeks) as well as nine adults were analyzed. The MLS appeared at Carnegie stage 15 (CS15), and until 12 weeks of gestation, abundant fibers of the intrinsic transverse muscle crossed the septum in the entire tongue. However, in near-term fetuses and adults, the contralaterally extending muscles were restricted to the deepest layer just above the genioglossus muscle. This finding indicates that the crossing transverse muscle showed the highest density at mid-term. A thorough understanding of both the MLS and the tongue muscles is necessary for successful tongue regeneration.

Comparative Assessment of Total Versus Hemi Glossectomy Defects Reconstructed With Anterolateral Thigh Free Flap

BACKGROUND

Free tissue transfers for reconstruction following tongue resection has become standard practice.

PURPOSE

This study sought to evaluate volume shrinkage of the anterolateral thigh free (ALTF) reconstructing tongue defects at 6 months postoperative. The aim was to estimate a shrinkage factor for ALTF reconstructing hemi and total glossectomy.

STUDY DESIGN, SETTING, SAMPLE

This was an IRB-approved retrospective cohort study conducted at the head and neck service at the University of Florida, College of Medicine, Jacksonville (FL). This study targeted patients with tongue cancer from January 2018 to April 2022.

INCLUSION CRITERIA

patients with tongue squamous cell carcinoma (SCC) who were surgically treated by either hemi or total glossectomy and reconstructed with ALTF. Patients had to have a postoperative computer tomography scans at 1 and 6 months post-surgery. Patients with constant body mass index during 6 months postreconstruction. Additionally, the patients were to have been treated with adjuvant radiotherapy.

EXCLUSION CRITERIA

patients with recurrent tongue cancer and those who weren't reconstructed or managed with other treatment modalities.

PREDICTOR VARIABLE

Type of tongue resection hemi versus total glossectomy for treatment of tongue SCC.

MAIN OUTCOME VARIABLE

Shrinkage percentage of ALTF reconstructing tongue defects at 6 months postoperatively.

COVARIATES

Age and gender.

ANALYSES

Paired t-test and student t-test with level of significance P ≤ .05 were used to statistically analyze ALTF volume changes at 1 and 6 months postoperatively and ALTF shrinkage percentage at 6 months postreconstruction, respectively.

RESULTS

We identified 85 patients who were treated for tongue SCC during the time period of study. Out of the 85 patients, 11 patients were reconstructed with an ALTF. Eight males and 3 females with a mean age of 62.3 years old. Six patients had total glossectomy and 5 had hemi glossectomy. Patients with hemi glossectomy had a significant difference in mean average flap shrinkage of 39.6%, while in those with total glossectomy had 17.7% (P = .004).

CONCLUSION AND RELEVANCE

According to our results, we recommend that the flap size should be larger than the defect to adjust for volume shrinkage (1.4 times and 1.2 times for cases of hemi and total glossectomy, respectively).

Anterolateral thigh, radial forearm and superficial circumflex iliac perforator flaps in oral reconstruction: a comparative analysis

BACKGROUND

Anterolateral thigh (ALT) and Radial forearm free flaps (RFFF) are historically the most common methods of oral reconstruction. The Superficial circumflex iliac artery perforator flap (SCIP) is an alternative providing a donor site that can be readily closed primarily with improved cosmesis in younger patients, due to its concealability.

METHODS

We reviewed 135 patients who received ALT, RFFF or SCIP flaps for oral reconstruction in our institution. Our aim was to compare operative and perioperative outcomes between each cohort. ANOVA and χ² test were used for statistical analysis.

RESULTS

There were 37 ALT, 64 RFFF and 35 SCIP reconstructions. Patients reconstructed with SCIP flaps had smaller resection volumes (P < 0.001) and earlier T and N classifications (P = 0.001, P = 0.008), and consequently reduced tracheostomy rates (P < 0.001), reduced need for enteral feeding at discharge (P < 0.001) and shorter length of stay and perioperative times (P < 0.001). SCIP flaps were more common in younger patients (P < 0.01). ALT flaps were used for more advanced disease (P = 0.001) and had larger resection volumes (P < 0.001) and increased need for assisted enteral feeding (P < 0.001). There were no significant differences in flap or donor site outcomes. There were two flap failures, both RFFF.

CONCLUSION

Each flap plays an important role in the reconstruction of oral defects, with larger defects preferentially reconstructed with ALT flaps. SCIP appears to be a reliable alternative in small defects with excellent perioperative and postoperative outcomes.

Features of the clinical course and prognosis of tongue cancer in young women

Introduction. In recent times, changes in epidemiology of tongue cancer have been observed. morbidity among nonsmoking and non-abusing alcohol young women have been rising. Currently, etiology and pathogenesis of tumor development in this nosological group are unclear and require detailed analysis of epidemiologic and clinical data.

Aim. To analyze the clinical material on the incidence of tongue cancer among young women (under 45 years old) over a 10-year period and assess the prevalence of this pathology in this group, the methods of treatment and reconstruction used, and determine the prognosis.

Materials and methods. The study included 68 female patients with squamous cell carcinoma of the tongue who received treatment between 2010 and 2020. mean age was 36.8 years (between 18 and 45 years; median – 39 years). None of the patients had history of alcohol abuse or smoking. In 32 (47.1 %) patients, primary diagnosis was made at stages I–II, in 36 (52.9 %) at stages III–Iv.

Results. In the last 10 years, a trend towards increased morbidity of tongue cancer among young women have been observed. In 2010, 2 cases of the disease were detected, in 2019–13, in 2020–14. mean follow-up duration was 40 months (median 32 months). Overall 5-year survival in this period was 72.5 ± 6.5 %, recurrence-free 5-years survival was 66.5 ± 6.6 %. Conclusion. Increase on tongue cancer morbidity among young non-smoking women is a new epidemiological trend worldwide. Etiological and pathogenetic factors of this trend have not been studied and require large multicenter studies for obtaining statistically significant results. Early medical resource utilization in this social group allows to perform adequate surgical intervention but requires the head and neck tumor specialist to pay attention to reconstructive surgery, quality and early patient rehabilitation allowing to preserve high quality of life, capacity for work and social activity.

Probable Change of Sleep Parameters after Resection and Reconstruction Surgeries in Patients with Oral Cavity or Oropharyngeal Cancers

In patients of oral cavity or oropharyngeal cancers, resection of the tumor and reconstruction of the defect may reduce the framework, add a bulky flap, alter the tissue flexibility, and contribute to postoperative obstructive sleep apnea (OSA). Postoperative OSA and the potential consequences may decrease the survival rate and reduce patients' quality of life. It is unclear whether the surgery is associated with postoperative OSA. Here, we compared the polysomnographies (PSGs) before and after the surgery in 15 patients of oral cavity or oropharyngeal cancers (out of 68 patients of head and neck cancers) without a chemo- or radio-therapy. Each patient received the second PSG before the start of any indicated adjuvant therapy to prevent its interference. There were 14 men and 1 woman, with a mean age and a standard deviation (SD, same in the following) of 56.2 ± 12.8 years. There were 6 tongue cancers, 5 buccal cancers, 2 tonsil cancer, 1 lower gum cancer, and 1 trigone cancer. The results show that the surgery changed sleep parameters insignificantly in apnea-hypopnea index (AHI), mean oxyhemoglobin saturation of pulse oximetry (SpO2), minimum SpO2, mean desaturation, and desaturation index but increased mean heart rate in the patients with free flaps. These results hint that the effect of surgery on developing OSA was small in this sample, with a longer plate or a larger framework for a bulkier free flap. It needs future studies with a large sample size to generalize this first observation.

Comparison of Donor Site Morbidity Between Anterolateral Thigh and Radial Forearm Free Flaps for Head and Neck Reconstruction: A Systematic Review and Meta-Analysis

ABSTRACT

This meta-analysis aimed to provide an up-to-date comparison of donor site morbidity (DSM) between patients who underwent head and neck reconstruction with Anterolateral thigh (ALT) and radial forearm free (RFF) flaps. We searched the PubMed, Web of Science, EMBASE, and Cochrane Library databases to identify studies that compared DSM between ALT and RFF patients. Study quality was assessed using the Newcastle-Ottawa Scale. The pooled odds ratio (OR) of each DSM between ALT and RFF patients was estimated using a random- or fixed-effect model depending on the degree of interstudy heterogeneity. Sensitivity and subgroup analyses were performed if substantial heterogeneity was detected. Eighteen cohort studies with 1,018 patients (535 ALT and 483 RFF patients) were included. Compared with RFF, ALT were associated with lower risks of wound dehiscence (OR = 0.2, 95%CI: 0.10-0.42, P < 0.01), strength impairment (OR = 0.18, 95%CI: 0.07-0.47, P < 0.01), and movement impairment (OR = 0.19, 95%CI:0.07-0.49, P < 0.01). A subgroup analysis showed that ALT were associated with a lower risk of donor site numbness among patients undergoing tongue reconstruction (OR = 0.05, 95%CI: 0.01-0.25, P < 0.01), but not among all patients undergoing head and neck reconstruction. The pooled ORs of other DSMs demonstrated no significant difference between ALT and RFF patients. ALT are superior to RFF for head and neck reconstruction in terms of donor site wound dehiscence, strength impairment, movement impairment, and for tongue reconstruction specifically in terms of donor site numbness. No significant differences in the incidence of donor site hematoma/seroma, infection, or dissatisfaction with donor site appearance were identified between ALT and RFF patients.

Donor site sequelae and patient satisfaction after head and neck reconstruction with a radial forearm free flap

PURPOSE

Radial forearm free flap (RFFF) being a workhorse flap in head and neck reconstruction, we investigated its donor site delayed consequences.

METHODS

Multicentric case series evaluating 189 patients who underwent RFFF for carcinologic reasons at least 6 months before. Patients and surgeon's appreciation regarding the aesthetic and functional consequences of the flap harvest on their daily life were evaluated by questionnaires using likert scales. Medical data were collected from patients' charts retrospectively.

RESULTS

Thirty percent of patients had at least one sequelae. Experiencing a graft necrosis did not worsen long-term results. Cosmetic satisfaction was significantly worst for women, according to patients' and surgeons' opinion. For 81% and 92% patients, respectively, the flap harvest had no impact on daily life nor sport practice. Ratio between the benefits of reconstruction and the sequelae at the donor site was judged "excellent" for 77% patients.

CONCLUSIONS

Although objectively important, RFFF morbidity has little impact in head and neck cancer patient's life.

Observational study of the long-term impact of donor-site sequelae after head and neck reconstruction by free anterolateral thigh flap

OBJECTIVE

Free anterolateral thigh flap has many applications in head and neck reconstruction surgery. The aims of the present study were: (1) to assess functional and esthetic sequelae of harvesting for oncologic purposes; and (2) to assess long-term impact of harvesting on quality of life according to patient and to physician.

MATERIALS AND METHODS

Forty-one patients undergoing reconstruction by free anterolateral thigh flap following oncologic head and neck surgery were assessed by questionnaire at>6 months postoperatively. Donor site sequelae were assessed in consultation. Harvesting impact was assessed on 5-point Likert scales by patient and by surgeon.

RESULTS

Thirty nine percent of patients showed≥1 sequelae. Donor site sequela impact on sport, daily living and work was assessed by patients as none or mild in 94%, 98% and 100% of cases, respectively. Sixty-one percent of patients and 58.5% of surgeons considered scar esthetics to be discreet or very discreet.

CONCLUSION

Morbidity related to anterolateral thigh flap harvesting was low, and functional sequelae at the donor site were well tolerated. The scar was only moderately satisfactory, but could easily be hidden.

Long-term donor site morbidity in head and neck cancer patients and its impact on quality of life: a cross-sectional study

Modern head and neck reconstructive surgery offers a multitude of different reconstructive options. In such cases, donor site morbidity is an important factor in the affected patient's decision-making. The aim of this study was to perform an objective comparison of donor site morbidity for the five most frequent microvascular donor sites in head and neck reconstructive surgery (radial forearm, anterolateral thigh, fibula, iliac crest, and scapula) using a uniform testing system. In this cross-sectional study, 117 donor sites were analyzed (106 for malignant disease and 11 for non-malignant disease): 73 radial forearm, 14 scapula, 12 anterolateral thigh, 10 fibula, and eight iliac crest. Testing consisted of range of motion, muscle strength, and sensation. The non-affected side served as the control. Quality of life was assessed using the Washington Quality of Life Questionnaire version 4 in its German translation. Range of motion was restricted in 15 cases (12.8%). Muscle strength was decreased in 58 cases (49.6%). Sensation was reduced in 70 cases (60%). Concerning quality of life, 31.2% of patients were limited in their daily activities. The scapula flap showed the highest incidence of overall donor site morbidity. However, correlation between objective and subjective donor site impairment was weak and the majority of patients experienced only minor limitations.

Ablation of Buccal Cancer and Functionality Buccal Reconstruction Using an Individuation Anterolateral Thigh Flap

The complex area for reconstruction of the head and the neck is the buccal because of difficult anatomy of this region. This article aimed to describe our individualized design for the reconstruction of the buccal using an different categories anterolateral thigh (ALT) flap. Ninety-four patients were involved in this study. Among 94cases, the number of using the musculocutaneous ALT flap was 57, using the fasciocutaneous ALT flap was 25, and using the thin ALT flap was 12. Postoperative vessel thrombosis occurred in 8 flaps, and required operative exploration in the perioperative period, 6 flaps were complete survival after the salvages, 2 flap was failure. The ALT flap represents a very good choice for the reconstruction of the complex defects at the cheek level. The flap can replace large volumes of tissues and the skin island is large and can be used both for the tegument reconstruction and for the oral mucosa reconstruction.

The anterolateral thigh flap for soft tissue reconstruction in patients with tongue squamous cell carcinoma

Background

Surgery remains the first choice of treatment for tongue cancer. Immediate reconstruction should be performed after wide resection of tumour. The aim of this study was to evaluate the anterolateral thigh flap for reconstruction of lingual defects.

Methods

We report 39 consecutive oral tongue squamous cell carcinoma patients who underwent lingual reconstruction with the anterolateral thigh flap between 2009 and 2010.

Results

The width of the skin island was 4 to 5 cm and the length of the skin island was 6 to 8 cm in 31 patients with T2 tumour, while the width of the skin island was 5.5 to 6 cm and the length of the skin island was 9 to 12 cm in 8 patients with T3/4 tumours. The all flap survival rate was 97.5 % in our series.

Conclusions

We could obtain sufficient flap volume using the anterolateral thigh flap for tongue reconstruction. The single perforator-based anterolateral thigh flap is a good option for soft tissue reconstruction in patients with oral tongue squamous cell carcinoma.

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.