Reconstruction of the base of the tongue with the microvascular ulnar forearm flap: a functional assessment

Ten patients with infiltrating carcinomas of the base of the tongue/tonsillar region underwent 30 to 100 percent resection of the base of the tongue and lateral pharyngeal wall. The surgical defect was reconstructed (9 primary, 1 secondary) with a large microvascular ulnar forearm flap that was selectively contoured to provide bulk for the base of the tongue and a thin lining for the pharyngeal wall. Seven patients were evaluated for swallowing and speech 6 weeks to 2 years following the reconstruction. Cineradiographic studies showed excellent base of the tongue and flap mobility allowing glossopharyngeal closure in all patients and complete pharyngeal evacuation in four patients. Four patients who were in good health preoperatively were able to eat a regular diet postoperatively, and the remaining three patients were able to handle soft food. Functional recovery after major tongue base surgery is contingent upon a three-dimensional microvascular reconstruction using a thin forearm flap.

Secondary microvascular tongue reconstruction: functional results

Between 1978 and 1991, 56 microvascular composite flaps were used for oromandibular reconstructions: 15 for primary total and subtotal tongue reconstruction and five for secondary major tongue reconstruction. The delayed reconstructions were performed to improve the oral and pharyngeal phases of swallowing. Using a floor of the mouth composite bone grafting technique to reposition the tongue and obliterate the oral dead space intraoral food transport was improved (three of five patients), but aspiration persisted (three of four patients). When compared with 10 patients evaluated for primary total and subtotal tongue reconstruction the primary reconstruction group showed superior swallowing (eight dynamic oral transport, no aspiration) and speech results. The poor results of secondary reconstruction are attributed to scarring and irreversible damage to remaining functional muscles involved in protecting the laryngeal aditus.

Total and subtotal glossectomy: function after microvascular reconstruction

Twelve patients with advanced carcinoma of the floor of the mouth and tongue were treated with total (five patients) or subtotal (seven patients) glossectomy, partial mandibulectomy, and immediate reconstruction with the microvascular composite groin flap. The osteomusculocutaneous groin flap was used in eleven patients, and the osteomuscular flap was used in one patient. The groin musculocutaneous or muscle flap was designed to resemble the shape of the tongue for dynamic food transport, improved swallowing, and acceptable speech. Eight of the 12 patients who survived more than 1 year were evaluated for speech and swallowing. Eight patients were able to speak intelligibly, six patients could tolerate a soft/pureed diet, and two patients were limited to fluids. Cinefluorographic swallow studies using semisolid contrast material showed voluntary active intraoral transport and propulsive pharyngeal emptying without aspiration in six patients with complete flap to palate contact; the remaining two patients were unable to move the intraoral contrast material effectively for swallowing because of poor palatal contact.

Adaptive mechanisms of speech and swallowing after combined jaw and tongue reconstruction in long-term survivors

Twelve patients have been studied for speech and swallowing function after major combined jaw and tongue reconstruction with the microvascular iliac bone and groin skin composite flap. Cinegraphic barium swallows demonstrated that for bolus propulsion, it is important to be able to occlude the palate with the flap. Glottic competence prevents aspiration. Speech studies show that although there is loss of certain speech sounds, approximate sounds are substituted. Speech is intelligible when soft-tissue contact to the palate can be accomplished. The adaptive mechanisms in these patients have been compared with the mechanisms used by a patient with uncorrected congenital aglossia and hypomandibulosis who developed excellent speech and swallowing. The mobility of this patient's mouth and pharynx was similar to that in the reconstructed cancer patients who were able to swallow and speak. This procedure has become our reconstruction method of choice for these major defects.