Tongue Reconstruction

  • 2nd most common area affected by oral cavity SCC after lip
  • Extent of surgical resection is the most important factor affecting function.
  • Better function results when more tongue musculature is left intact

Small (<1/4) defects

  • closed primarily with maximum preservation of tongue mobility and function.

Hemiglossectomy defect (25-75%)

  • best reconstructed with a thin fasciocutaneous flap
  • thin flap will provide adequate bulk for these defects, but more important, a thin flap with proper insetting preserves the mobility of the remaining tongue without tethering

Subtotal glossectomy (>75%)

  1. problems (speech, swallow, feed, aspiration)
  2. Resection of the intrinsic tongue musculature prevents active intraoral foodtransportation and inhibits accurate articulation.
  3. Loss of the mylohyoid sling removes support of the floor of the mouth and prevents elevation of the base of the tongue to meet the palate, affecting speech and swallowing.
  4. airway protection - unable to diverts saliva and food to the lateral gutters during swallowing increases risk of aspiration
  • Aims
  • add bulk
  • decreases the volume of the oral cavity
  • a shelf above the laryngeal inlet to direct the food bolus down the posterior pharyngeal wall and lateral gutters
  • allows contact with the soft palate, assisting with caudal propulsion of food, decreasing resonance and improving vocal quality
  • for total defects, rectus myocutaneous flap have been used (muscle and skin graft in more obese patients)
  • musculocutaneous flap replacing the tongue should be cylindrical in shape, touching the hard and softpalate and completely obliterating the oral cavity whenthe jaw is closed. The anterior sulcus is made shallowerthan the lateral sulci to enhance salivary drainageand prevent pooling
  • lateral arm flap has thickness intermediate between that of the radial forearm and the rectus abdominis flaps and has minimal donor site morbidity. However, it has a relatively short pedicle (approximately 6 cm) and small vessels (1.5 mm)
  • restoration of mucosal surface to preserve mobility of the remaining tongue
  • requires proper flap insetting to recreate the sublingual sulcus and the lateral gutter
  • restoration of sensation
  • sensation in the oral cavity contributes to the swallowing mechanism
  • reduce drooling
  • reduce pooling
  • better oral hygiene – debris detection
  • Boyd et al observed near-normal sensory recovery of the radial forearm free flap once it had been transferred intraorally with reinnervation of the lateral antebrachial cutaneous nerve to the lingual nerve in eight patients with partial glossectomy defects. They also demonstrated that flap sensation was superior to that in the native forearm skin. Apparently, this was due to the much larger cortical representation of the recipient nerve.
  • Santamaria et al found similar results in a larger series at the ChangGungMemorialHospital in Taiwan. The investigators further demonstrated that only the lingual and alveolar nerves provided adequate sensory recovery but not the posterior auricular nerve and the cervical plexus.
  • Unlike the antebrachial cutaneous nerve of the radial forearm flap, which is a pure sensory nerve, the intercostal nerve of the rectus abdominis flap is a mixed nerve composed of 70% motor and only 30% sensory fibers, resulting in inferior sensory recovery
  • Anterolateral thigh flap - coaptation of the lateral femoral cutaneous nerve to the lingual nerve
  • Postreconstruction radiotherapy (mean dose: 60 Gy) significantly delayed sensory recovery but the end results were no different after 12 months
  • motor innervation
  • technically impossible to recreate the fine movements of the intrinsic/extrinsic tongue musculature
  • usually only one vector.
  • Radiation will cause significant muscle atrophy
  • In selected patients with a good prognosis and no need for postoperative radiotherapy, motor nerve reinnervation may achieve some degree of muscle movement and prevent the muscle flap from undergoing atrophy.
  • Innervated muscles include
  1. lat dorsi (thoracodorsasl to hypoglossal)
  2. gracilis
  3. rectus
  4. ALT – to vastus lateralis (only flap that can have both motor and sensory reinnervation)
  5. Restore Taste
  6. Cannot be reconstructed at this stage
  7. Prevent aspiration
  8. Laryngeal suspension effectively moves the larynx anterior-superiorly into a more physiologic position, decreasing postoperative aspiration (circumhyoid sutures -0 Prolene) placed through the drill holes in the mentum on both sides of the midline as described by Weber et al
  9. Maintaining an intact superior laryngeal nerve is essential if laryngeal preservation is attempted
  10. Preservation of the base of the tongue, if oncologically feasible, may assist in triggering the reflux laryngeal protective mechanisms.
  11. Tracheostomy may be required if risks remain high