Tongue Reconstruction Research Articles

Isolated aglossia in a six year old child presenting with impaired speech: a case report

IntroductionThe most mobile organ of the body, the tongue is associated with various congenital anomalies; most of which are in association with many other systemic abnormalities. Rarely do they occur in isolation. Isolated aglossia, that we presented, is one of the more rare presentations.Case presentationOur patient is a 6-year-old male child of Asiatic origin from Kashmir (India), who was physically well built and mentally sound and presented with history of impaired speech. The patient had normal velopharangeal competence but absence of tongue which was replaced by a small mucus membrane projection near the floor of oropharangeal isthmus. The patient had no difficulty in feeding or taste sensation but he was unable to pronounce lingual consonants.ConclusionIsolated aglossia is very rare condition explained on the basis of growth failure of lateral lingual swellings and tubercular impar. Such patients do not usually need reconstruction of tongue; as feeding, swallowing and taste sensations are usually intact and speech cannot be improved by reconstruction. However, malocclusion of teeth needs to be taken care of.

Radial Forearm Flap for Tongue Reconstruction

Objective: To present a case of tongue reconstruction using radial forearm free flap.
 Methods:
 Design: Case Report
 Setting: Tertiary government hospital
 Patient: One
 Results: A 52-year- old female with a T3N2cM0 Stage IVa right tongue carcinoma underwent tracheotomy, right hemiglossectomy with modified radical neck dissection type III and extended supraomohyoid neck dissection on the left with radial forearm free flap reconstruction. After 1 month, the radial forearm free flap reconstruction in the tongue had acceptable appearance and good tongue mobility with intelligible speech. The patient did not complain about the appearance and function of the left forearm.
 Conclusion: The radial forearm free flap is a viable reconstructive option for tongue defects
 especially where a thin, pliable flap is needed. There is acceptable form and functional restoration with minimal donor site morbidity.
 Keywords: radial forearm free flap, tongue reconstruction

Cine-MRI swallowing evaluation after tongue reconstruction

Objective To determine the feasibility of cine-MRI for non-invasive swallowing evaluation after surgery for lingual carcinoma with reconstruction using microvascular free flaps. Methods Ten patients with stage IV carcinoma of the mobile tongue and/or tongue base treated by surgical resection and reconstruction with a free flap were evaluated after an average of 4.3 years (range: 1.5–11 years), using cine-MRI in “single-shot fast spin echo” (SSFSE) mode. Fiberoptic laryngoscopy of swallowing was performed before MRI to detect aspiration. The tolerance and ability to complete the exam were noted. The mobilities of the oral and pharyngeal structures visualized were evaluated as normal, reduced or increased. Results Cine-MRI was well tolerated in all cases; “dry” swallow was performed for the 2 patients with clinical aspiration. Tongue base-pharyngeal wall contact was observed in 5 cases. An increased anterior tongue recoil, increased mandibular recoil, increased posterior oropharyngeal wall advancement and an increased laryngeal elevation were observed in 4 cases. One case of a passive “slide” mechanism was observed. Conclusions Cine-MRI is a safe, non-invasive technique for the evaluation of the mobility of oral and oropharyngeal structures after free-flap reconstruction of the tongue. For selected cases, it may be complementary to clinical examination for evaluation of dysphagia after surgery and free-flap reconstruction. Further technical advances will be necessary before cine-MRI can replace videofluoroscopy, however.

Beavertail modification of the radial forearm free flap in base of tongue reconstruction: Technique and functional outcomes

Head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure with the preservation of function when deciding the patient's best treatment protocol. This task is especially difficult in cancer of the base of tongue. The purpose of this manuscript is to describe the beavertail modification of the radial forearm-free flap in base of tongue reconstruction. Thirty-one consecutive patients treated for base of tongue cancer with primary surgery were followed prospectively. The technique of the beavertail modification is described. Swallowing and speech function were assessed preoperatively and postoperatively. All the flaps survived. Thirty (97%) patients started consuming oral diet within 1 year, and all had normal speech intelligibility. The beavertail modification of the radial forearm arm flap seems to provide the reconstructive elements that allow patients with large base of tongue extirpations to develop functional swallowing and speech production postoperatively.

Microvascular Free Tissue Transfer for Tongue Reconstruction After Hemiglossectomy: A Functional Assessment of Radial Forearm Versus Anterolateral Thigh Flap

The purpose of this study was to evaluate tongue function and donor site morbidity in patients with oral cancer surgically treated and reconstructed with radial or anterolateral thigh free flaps. Twenty patients underwent primary reconstruction after hemiglossectomy between January 2002 and June 2004. Ten patients were reconstructed using a free forearm flap and the remaining with an anterolateral thigh flap. Eight patients on each group underwent postoperative radiotherapy (average, 60 Gy). All of them were followed postoperatively to determine after 6 months their functional outcome as it related to speech, deglutition, tongue mobility, and donor site morbidity. The intelligibility, deglutition, and tongue mobility were each scored on a scale ranging from 1 to 7 by an independent investigator. Data were analyzed by the 2-tail Mann-Whitney U test. No differences in mean speech intelligibility, tongue mobility, or deglutition mean scores were seen between radial forearm flap and anterolateral thigh flap (P > .05). In all anterolateral thigh flap-treated cases, the donor site was closed directly and no complications were seen. However, in all forearm flaps donor site closure was carried out with skin grafts and dorsal forearm splinting was applied for 1 week postoperatively. In 4 cases a partial skin graft failure was observed and donor sites healed for second intention. Anterolateral thigh flap, with its versatility in design, long pedicle with a suitable vessel diameter, and low donor site morbidity, could be the ideal flap for hemiglossectomy defect reconstruction.

Quality of life after free-flap tongue reconstruction

To analyse correlations between quality of life measures, aspiration and extent of surgical resection in patients who have undergone free-flap tongue reconstruction. Nine consecutive patients (seven men and two women; average age 51 years) who had been diagnosed with T4a carcinoma of the mobile tongue and/or tongue base and treated by glossectomy, free-flap reconstruction, and either radiation therapy or chemoradiation responded to the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire, the performance status scale questionnaire and the hospital anxiety-depression scale questionnaire, an average of 43 months after treatment (range 18-83 months). Aspiration was evaluated by fibre-optic laryngoscopy. Correlations between quality of life domain scores, extent of surgery and the presence of aspiration were evaluated using non-parametric statistical analysis. Scores for the swallowing and aspiration domains of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire were significantly correlated with the extent of tongue base resection (Spearman's correlation, p = 0.037 and 0.042, respectively). Despite a strong correlation between the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire results and the performance status scale global scores (correlation coefficient = 0.89, p = 0.048), the performance status scale domain scores were not correlated with the extent of tongue resection. Clinically apparent aspiration was not correlated with the extent of tongue resection, nor were the anxiety or depression scores. However, clinically apparent aspiration was significantly related to the swallowing and aspiration domain scores of the European Organization for Research and Treatment of Cancer Head and Neck-35 questionnaire (p = 0.017 in both cases). Our results imply that the volume of tongue base resection is a major factor in swallowing- and aspiration-related quality of life following tongue resection and free-flap reconstruction. Free-flap reconstruction does not seem to palliate the effect of the loss of functional tongue base volume, as regards swallowing-related quality of life.

O.312 Buccinator myomucosal island flap for tongue reconstruction

The full thickness, posteriorly based, lateral tongue flap is described and the excellence of the blood supply is emphasised. The surgical technique is discussed and the application of the flap in the reconstruction of defects of the palate, cheek and floor of the mouth is illustrated. The versatility of the method is stressed, together with method is stressed, together with advantages over regional skin flaps when used for the same purpose.

Triple Skin Island Fibula Free Flap: A Good Choice for Combined Mandible and Tongue Defect Reconstruction

Resections of malignant tumors involving the mandible and anterior tongue result in complex defects that are still real challenges for reconstructive surgeons. Whereas there are preferred methods for mandible reconstruction involving isolated or limited loss of soft tissues, there are no standards for extended bone-soft tissue intraoral defects. This article documents the modification of the fibula free flap where triple skin islands are used for reconstruction of anterior tongue and floor of the mouth. The technique also includes filing the submandibular space with an isolated part of the flexor hallucis longus muscle, based on individual perforator. The details of flap designing, harvesting, and insetting are also presented. Eight such reconstructions have been performed on patients who underwent complex resection of the anterior mandible together with the mobile part of the tongue. Flap survival rate was 100%. In all eight cases, understandable speech and return to unrestricted diet mastication and swallowing were achieved. Analysis of aesthetic effects showed generally very good results. The presented modification of fibula free flap can be an alternative to double flaps in complex reconstruction of the mandible and mobile tongue.

WITHDRAWN:One-Stage Reconstruction of the Tongue using the Infrahyoid Myocutaneous Flap after Resection for Oral Cancer as an Alternative to Free Flaps.

Ahead of Print article withdrawn by publisher:OBJECTIVES/HYPOTHESIS:: The aim of this study was to describe our results in reconstructive surgery after cancer ablation using the less popular infrahyoid myocutaneous flap as an alternative method to free flaps. Infrahyoid muscles are very useful as a neurovascular myofascial flap in plastic reconstructive surgery of the upper aerodigestive tract, particularly in the restoration of the muscular components in small and medium tongue defects. The surgical technique and the postoperative outcomes are described. STUDY DESIGN:: Retrospective study. METHODS:: During the period 2000 to 2006, 32 patients with squamous cell carcinoma of the tongue were surgically treated using a pure infrahyoid myocutaneous neurovascular flap. RESULTS:: The flap was successful in all cases without flap necrosis, fistula or complications in the donor site. Spontaneous epithelization of the flap took about 2 months to complete, with no evidence of scarring and/or shrinkage. After radiation therapy, flap tissues remained sufficiently soft, trophic, and mobile. Ultrasound evaluation of tongue mobility performed at the time of discharging and 3 and 6 months after surgery, showed normal bolus propulsion. Cinefluoroscopy also showed good function of the reconstructed tongue. CONCLUSIONS:: Tongue reconstruction with a microvascular anastomosed flap can improve functional results after cancer resection. However, in our experience using monolateral or bilateral infrahyoid myocutaneous flap is less time consuming and reduces the complication rate and the operation time in both small and large defects. The main advantage of this flap is its voluntary innervation by the ansa cervicalis and the prevention of scarring and atrophy of the neotongue.

Functional Reconstruction of Glossectomy Defects: The Vertical Rectus Abdominus Myocutaneous Neotongue

The vertical rectus abdominus myocutaneous (VRAM) flap is a valuable option for tongue reconstruction. However, the traditional inset (skin to remaining oral mucosa) obviates a more anatomic reconstruction. Eight patients underwent total or subtotal glossectomy with VRAM reconstruction. The muscle inset was supported at the inferior mandibular border attached to the remaining lingual mucosa or gingiva. The neotongue, consisting of skin and subcutaneous fat, was sutured posteriorly to the remaining tongue base, and the other surfaces were trimmed and left unsutured. Reconstruction was successful in all patients. The neotongue assumed palatal configuration, and within 2 weeks uniform granulation tissue followed by mucosalization occurred. One year postoperatively, all patients tolerated ad lib diets, spoke intelligibly, were gastrostomy tube and tracheotomy free and had no evidence of aspiration. This neotongue sits on the mandible under voluntary control, permitting effective obturation against the hard palate and providing successful speech and swallowing.

A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients

For tongue reconstruction after total or subtotal glossectomy, a rectus abdominis musculocutaneous flap is often used to obtain sufficient flap volume. However, thin patients often have too little fat tissue to ensure adequate flap volume. For this reason we developed a new flap design to compensate for insufficient flap volume in thin patients. In this series, total or subtotal glossectomy was performed in 20 thin men with a mean age of 58.3 years. The patients had a mean body mass index of 18.22 kg/m(2) and most were considered emaciated. The defects were reconstructed using a rectus abdominis musculocutaneous flap with two skin islands. The first skin island was used to reconstruct the mucosal defect, and the second was de-epithelialised and used to increase flap volume. Flaps were transferred successfully in 19 out of 20 patients. Most patients could tolerate more than a soft diet without severe aspiration and could engage in conversation. However, four patients required total laryngectomy or a permanent stoma owing to severe aspiration. In this series, the larynx could be preserved in 80% of thin patients, and satisfactory postoperative oral function was obtained. The most important point for obtaining satisfactory oral function is to reconstruct a tongue with a protuberant shape and sufficient volume. We could maintain sufficient flap volume with the de-epithelialised skin island of a rectus abdominis musculocutaneous free flap. We believe our new flap design is effective for tongue reconstruction in thin patients.

Tongue reconstruction with anterolateral thigh flap for middle-late stage tongue cancer patients

Objeetive To investigate the outcome of microvascular reconstruction of the tongue with anterolateral thigh flaps in the treatment of middle-late stage tongue cancer patients. Methods From December 2003 to March 2007,nine patients underwent simultaneous reconstruction of the tongue and oral floor defects with anterolateral thigh flaps after resection of squamous cell carcinoma of tongue.The flaps ranged from 7 cm×10 cm to 10 cm×12 cm in size,and were adjusted to the defect of the tongue and oral floor.The vascular pedicle included descending branch of the lateral femoral circumflex artery and the accompanying veins.The outcome of reconstruction was evaluated by follow-up examinations,considering the contour and mobility of the reconstructed tongues,the swallowing function and the speech function.Results All of the donor sites were closed directly,with minimal donor-site morbidity. All patients recovered unevenffully from surgery,with no immediate postoperative complications:no flap necrosis,no wound infection or wound dehiscence.The transplanted flaps survived well.The average follow-up period was 18 months.During the follow-up period there was no tumor recurrence and the contour of the reconstructed tongues showed sufficient bulk.The patients demonstrated good mobility of the reconstructed tongue.The swallowing and speech function recovered satisfactory.Two months postoperatively the patients were able to ingest a solid or semisolid diet,and six months postoperatively the patients developed intelligibe language.Conclusion The anterolateral thigh flaps are suitable and reliable for the microsurgical reconstruction of the large defects caused by middle-late stage tongue cancer. Key words: Tongue neoplasms; Anterolateral thigh flap; Transplantation; Microsurgieal operation

A Comparative Anatomical Study of Brachioradialis and Flexor Carpi Ulnaris Muscles: Implications for Total Tongue Reconstruction

Total or subtotal glossectomy following resection of intraoral tumors causes significant morbidity. Recent surgical endeavors have focused on the creation of a neotongue with both sensory and motor innervation. Although various local or regional free flaps have been used for this purpose, the optimal donor site remains undecided. The authors compared the neurovascular anatomy of the brachioradialis and flexor carpi ulnaris to assess their suitability as donor muscles together with overlying skin for functional total or subtotal tongue reconstruction. Eighty-eight brachioradialis and 80 flexor carpi ulnaris muscles were studied, comprising 120 dissected specimens, 18 arterial studies, two venous studies, 20 histologic studies, and eight neurovascular studies. The dominant vascular pattern of the brachioradialis varied. The major pedicle arose from the radial (38 percent), radial recurrent (42 percent), and brachial arteries (20 percent). The muscle also lacked a single neurovascular pedicle. The vasculature of the flexor carpi ulnaris was consistent. The ulnar artery supplied the dominant pedicle in 86 percent of cases. The entry point of motor innervation is near that of the vascular pedicles. A minor distal nerve accompanied the main vascular pedicle in 65 percent of cases. The overlying skin was supplied by musculocutaneous perforators. The lower lateral cutaneous nerve of the arm supplied the skin over the brachioradialis, and the medial cutaneous nerves of the arm and forearm provided sensation over the flexor carpi ulnaris. The authors delineated the anatomical advantages of the flexor carpi ulnaris over the brachioradialis for total or subtotal tongue reconstruction.

A massive arterial thrombosis of a free anterolateral thigh flap in a patient with antiphospholipid syndrome

The antiphospholipid syndrome is a pathological condition characterized by recurrent thrombotic manifestations in venous and/or arterial vascular systems and by peculiar laboratory findings as anticardiolipin antibodies and/or positive lupus anticoagulant. We present a case of massive pedicle thrombosis of a free anterolateral thigh perforator flap used for tongue reconstruction following hemiglossectomy in a patient with antiphospholipid syndrome, which compelled us to an immediate second reconstruction choice with a radial forearm free flap. This case is an example of how this syndrome, especially if unknown before surgery, can influence the outcome of microsurgical transfer of flaps.

Medial sural artery perforator flap for tongue and floor of mouth reconstruction

The radial forearm flap is frequently considered the first choice for tongue reconstruction, but the disadvantages of donor site morbidity are well known. The search for another thin skin flap as an alternative has led to the application of the medial sural artery perforator flap. We used 12 medial sural artery perforator flaps to reconstruct tongue and floor of mouth following cancer ablation. We paid attention to the major perforator (vein >or= 1 mm) as the vascular relay. Most flaps were raised with a single perforator. The size of the skin paddle varied from 9 cm x 5 cm to 14 cm x 12 cm. The mean thickness of the flap was 5.2 mm. We reexplored 1 patient for venous insufficiency and could not salvage the flap. The thin medial sural artery perforator flap permits high accuracy of tongue restoration and reduces the morbidity at the donor site.

Microscopic Resconstruction Using Implants for Mandibular Reconstruction

The recent development of oral and maxillofacial surgery is focusing on the recovery of oral and maxillofacial function, including mastication, swallowing and articulation. For that purpose, oral and maxillofacial surgery will be hardly conceivable without the concept of dental implantology. Mandibular reconstruction is performed with free bone grafts of the scapula, Ilium, fibula with vascular pedicles. Osseointegrated implants are currently set in the reconstructed mandible for functional reconstruction. In this study, vascularized bone grafts appropriate for mandibular reconstruction were evaluated for subsequent implant grafting in the reconstructed mandible. The cross sectional internal structure of the mandible, as will as the scapula, ilium, fibula and ribs which were examined by scanning electron microscopy, and bone morphologic features were compared. The results were follows: The largest amount of bone was ilium, and the mineralized bone was highest in fibula. Therefore the ilium was used frequently for reconstruction surgery. In our recent 50 cases of mandibular and tongue reconstruction cases using vascularized iliac crest, implant was performed in 15 out of the 50 cases. We have done alveolar cleft bone grafting for over 86 cases. Among the presented cases, 12 cases were inserted by dental implant. The result was all satisfactory. Distraction-osteogenesis which could replace major part of bone grafting is the future. This technique will be very useful for dental implantology. Our 32 cases of dental implants combined with this technique is presented. Facial implant is different in concept from dental implant. It might be said that the condition of facial implant is more severe than that of dental implant. However, the role of implant as an excellent anchor for the prosthesis has to be emphasized again.

Tongue reconstruction: recent advances

To examine the recent literature concerning advances in tongue reconstruction after tumor resection. Reconstruction following resection of malignant tongue tumors remains one of the most difficult problems in head and neck oncology. Recent trends in tongue reconstruction have focused on optimizing speech and swallowing function and maximizing quality of life. In the recent literature, several new reconstructive strategies including omohyoid musculocutaneous and myofascial flaps overlayed with radial forearm free flaps have been described. In addition, several older reconstructive options, such as trapezius and pectoralis rotational flaps, have been revisited. There has also been a trend toward restoring innervation to these flaps rather than leaving them insensate. Tongue cancer resection and subsequent reconstruction pose interesting challenges to the surgeon to maximize postoperative function and quality of life. Attention to the principles of tongue reconstruction and knowledge of the range of available reconstructive options can result in more favorable functional outcomes.

舌口腔底再建における工夫

舌口腔底切除では残存組織の機能を最大限に引き出すような再建が必要となる。今回，我々の舌口腔底再建の工夫について報告する。対象：舌口腔底癌で切除後即時再建を行った110例を対象とした。再建組織は腹直筋皮弁61例，前腕皮弁33例，その他16例。再建における工夫：目標は隆起した舌形態をつくることで，口腔底欠損部へ十分な組織移植を行い，術後に皮弁沈下を予防するために口腔底隔膜を再建することが重要となる。舌側方欠損では残存舌を十分に伸ばし縫合すると舌尖の動きを妨げない。舌根部のボリュームを得るために，皮弁の一部を脱表皮し舌根に充填する。デザインは紡錐形であるが，腹直筋皮弁では皮下組織の多い臍周囲を舌根部へ，皮下の薄い部分を舌可動部にあたるよう縫合する。前腕皮弁では大きく紡錐形をデザインし，皮弁の近位部分を脱表皮して口腔底へ充填する。舌2/3切以上では腹直筋前鞘で口腔底隔膜を再建し，喉頭挙上する。

FREE RADIAL FOREARM FLAP AFTER PARTIAL GLOSSECTOMY FOR SQUAMOUS CELL CARCINOMA OF THE TONGUE

Squamous cell carcinoma of the tongue is a highly malignant conditionand results in high mortality and morbidity in patients despite its early detection (1). Early surgical interventions have been found to reduce mortality but in many reports, tongue reconstructions using live grafts have been found to reduce normal tongue function of speech, swallow and taste. In contrast, our report using free radial forearm flap (FRFF) to reconstruct the defect left over after a radical tongue resection in a38-year-old gentleman with oral cancer has shown promising results. This type of reconstruction has left the patient with a functional and cosmetically acceptable tongue with minimal alteration in recognizable speech.

Total Tongue Reconstruction with Free Rectus Abdominis Myocutaneous Flaps: Functional Results

Total Tongue Reconstruction with Free Rectus Abdominis Myocutaneous Flaps: Functional Results