Modification of flap design for total mobile tongue reconstruction using a sensitive antero-lateral thigh flap

A novel flap design technique for subtotal tongue reconstruction with an "Individualized and Convenient Tongue Model"

BACKGROUND

To achieve improved functional outcomes in subtotal tongue reconstruction, a flap design with sufficient volume and appropriate shape is necessary. In this study, we introduce an "Individualized and Convenient Tongue Model" (ICTM) for flap design in subtotal tongue reconstruction.

METHODS

By studying the anatomical morphology of the tongue, we found a similar geometry within the dorsum and body of the tongue as well as the mouth floor. This can be used to create an ICTM through folding and splicing. We can simulate tongue defects in the ICTM and transform defect shapes into guide plates for flap design. In this study, fifty-eight patients requiring subtotal tongue reconstruction were randomly divided into two groups: an ICTM group (35 patients) and a conventional group (31 patients). In the ICTM group, we individually designed profunda artery perforator flaps (PAPFs) or anterolateral thigh flaps (ALTFs) using the ICTM method. In the conventional group, the flap was designed according to the surgeon's clinical experience. Patient demographics, operative and follow-up data were recorded. Swallowing, speech intelligibility, and cosmetic results were assessed using appropriate scales.

RESULTS

All flaps survived, although there were no significant differences in tumor size, operation time, flap size, and complication rate compared to the conventional group. Patients in the ICTM group had significantly improved speech intelligibility (p = 0.019), cosmetic appearance (p = 0.009), and swallowing ability (p = 0.003).

CONCLUSIONS

The ICTM technique is an effective and convenient solution for subtotal tongue reconstruction that provides an individualized flap design and improves functional outcomes compared to the conventional design.

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.

Optimization of total tongue functional reconstruction with the sushi roll technique and its application in pectoralis major myocutaneous flaps

A protuberant shape and sufficient volume are the most important parameters for total tongue reconstruction. The conventional pectoralis major myocutaneous (PMMC) flap undergoes collapse due to atrophy of the denervated muscle. In a new technique, this flap was rolled up like sushi to reshape the neotongue. This study explored the feasibility and effect of the 'sushi roll' technique for precise total functional reconstruction of the tongue using a PMMC flap. Thirty patients scheduled for total glossectomy and PMMC flap reconstruction were recruited. The sushi roll technique was performed in 15 patients and the conventional repair in 15 patients. Outcomes were compared between the two groups. The flap survived in all 30 patients. The sushi roll group showed superior results to the conventional group in terms of time to oral alimentation (P = 0.012) and decannulation (P = 0.041), as well as swallowing function (P = 0.032), speech intelligibility (P < 0.001), shape (P < 0.001), and quality of life score (P < 0.001) at 12 months. The innovative sushi roll technique uses a folding method that utilizes the length rather than the thickness and width of the flap to maintain the volume and protuberance of the neotongue, which results in acceptable function and improved quality of life.

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.

Functional tongue and floor of mouth reconstruction with a chimeric flap after total glossectomy

PURPOSE

Presently, the functional reconstruction of the tongue in patients after subtotal or total glossectomy with the removal of the oral floor muscles and spearing of the larynx remains a complicated and unsolved issue. The aim of this case is to describe a method reconstruction of the tongue in patients after total glossectomy with the removal of the oral floor muscles using the chimeric latissimus dorsi and serratus anterior free flap (chimeric LD + SA flap) with motor innervation.

METHODS

A 62-year-old woman with advanced cancer of the oral cavity was submitted to total glossectomy and then reconstruction with a chimeric LD + SA flap. With this method reconstruction of the tongue was made the creation a large mound (neotongue) lateral to the mandibular arch which can easily reach the palatal arch and also was made suspension of the larynx is essential given the ablative loss of supra-hyoid attachments.

RESULTS

Our preliminary experience shows that this flap is a good reconstructive option for total glossectomy with the removal of the oral floor muscles and with larynx preservation. Functional and objective evaluation of the tongue reconstructed with chimeric LD + SA free flap requires further and standardized evaluation.

Usefulness of a template-based anterolateral thigh flap for reconstruction of head and neck defects

BACKGROUND

One of the challenges in head and neck reconstruction is to have an adequate understanding of the three-dimensionalities of the defects created after resections due to the high variability of clinical scenarios. Consequently, it is essential to design the flap to match the requirements of the defect in order to facilitate the insetting and to achieve a successful outcome. The anterolateral thigh flap (ALT) is a robust and versatile flap commonly used in head and neck reconstruction. In this study the authors use a hand-made template as a tool to customize ALT flaps and its variations to fit more accurately the different shapes, volume, and components of the resulting defects. The aim of this study is to describe in detail this surgical approach and present the clinical experience in 100 consecutive cases using a template-based ALT flaps in head and neck reconstruction.

METHODS

A retrospective review was performed on all microvascular head and neck reconstruction cases between January 2013 and December 2017 in our institution where a template-based ALT flap design was performed. We describe in detail the surgical technique used and present the clinical outcomes. In addition, we analyzed the use of different designs of the ALT flaps including different flap components in relation to the location of the defect.

RESULTS

One hundred reconstructions for head and neck defects were performed in 97 patients. Seven types of ALT free flaps were performed: fasciocutaneous (46%), suprafascial (8%), adipofascial (9%), vastus lateralis muscle (3%), composite fasciocutaneous/adipofascial (9%), chimeric flaps (21%), and vascularized nerve grafts (4%). Oropharyngeal and periauricular defects were mostly reconstructed with fasciocutanoues design. In more complex three-dimensional defects such as skull base or midface defects, a chimeric flap was selected. In all cases the used of template facilitated the insetting of the free flap. The total flap loss was 2%.

CONCLUSIONS

Customization of ALT flaps using intraoperative templates is a useful method for flap design which facilitates fitting of the flap to a variety of defects in head and neck reconstruction.

"Sushi roll" technique for precise total tongue functional reconstruction using a pre-sutured femoral anterolateral myocutaneous flap

OBJECTIVES

Reconstruction of the total tongue after cancer resection remains one of the challenges in head and neck surgery. Inadequate reconstruction after subtotal or total glossectomy defects leads to poor quality of life. The aim of this study was to explore an economical, practical and effective flap design for functional tongue reconstruction.

MATERIAL AND METHODS

Sixty patients were randomly divided into two groups, namely, a "Sushi roll" technique group (30 patients) and a conventional surgery group (30 patients). Then, the patients underwent total or subtotal tongue reconstruction. Swallowing function, speech intelligibility, cosmetic results, and quality of life were assessed with the appropriate scales. Outcomes were analysed, and a p-value <0.05 was considered significant.

RESULTS

The perioperative recovery of the "Sushi roll" group was superior to that of the conventional group. Relative to patients in the conventional group, patients in the "Sushi roll" group showed significantly improved speech intelligibility (p = 0.025), cosmetic results (p < 0.001) and swallowing function (p < 0.001).

CONCLUSION

The innovative "Sushi roll" anterolateral thigh myocutaneous flap approach for total tongue reconstruction creates a free neotongue tip with adequate volume and protuberance and causes minimal damage to the donor site, producing acceptable swallowing function and speech intelligibility.

Tongue reconstruction: Rebuilding mobile three-dimensional structures from immobile two-dimensional substrates, a fresh cadaver study

OBJECTIVE

To determine the two-dimensional (2D) characteristics of flaps necessary to create three-dimensional (3D) tongue anatomy.

METHODS

Dissection of 11 fresh, nonpreserved human cadavers was performed. Six defects in each were created: total tongue, total oral tongue, hemiglossectomy, oral hemiglossectomy, total base of tongue, and hemi-base of tongue. The resections were debulked to create flat, 2D mucosal flaps. The dimensions and shapes of these flaps were determined.

RESULTS

Each specimen showed consistent dimensions and geometry between cadavers. The total tongue was pear-shaped, the total oral tongue was egg-shaped, the oral hemi-tongue was bullet-shaped, the hemi-tongue resembled a dagger, the total base of tongue was rectangular, and the hemi-base of tongue was hour-glass shaped.

CONCLUSION

Typical dimensions and shapes of common tongue defects were determined. It is conceivable that customizing reconstructive flaps based on these data will increase the accuracy of neo-tongue reconstruction, and thus, improve functional outcomes.

"Five-point eight-line" anatomic flap design for precise hemitongue reconstruction

BACKGROUND

Reconstruction of hemiglossectomy defects requires careful flap design to avoid adverse functional and aesthetic outcomes.

METHODS

Hemitongue specimens were obtained from minipigs to study the three-dimensional anatomy and to define anatomic landmarks for precise measurements of flap requirement. The concept developed in animal models was then applied to hemiglossectomy reconstruction in clinical practice. Sixty-one patients were randomly enrolled into the following two groups: a "five-point eight-line segment" (FIPELS) flap design group (28 patients) and a conventional group (33 patients). Functional and aesthetic outcomes were compared between the two groups.

RESULTS

All flaps designed with the FIPELS technique matched the hemiglossectomy defects without the need for flap trimming, thus reducing the operating time (P = .03). Swallowing functions, speech intelligibility, and aesthetic outcomes were superior in the FIPELS group than that in the conventional group (P < .05).

CONCLUSIONS

The FIPELS flap design for hemiglossectomy reconstruction yields improved functional and aesthetic outcomes compared to a conventional flap design.

Primary clear cell sarcoma of the tongue and surgical reconstruction: About a rare case report

Clear cell sarcomas (SCC), also called "soft-tissue melanoma", are rare and aggressive tumors that preferentially affect the lower limbs (tendons and fasciae) and which have also been described in head and neck localizations. Their clinical and immunohistochemical mimicry with melanoma makes it difficult to diagnose sarcomas. SCC treatment is mainly focused on large-scale resection surgery with adjuvant radiotherapy because of their low chemo-sensitivity and extreme lymphophilia. In case of head and neck localization, these treatments may lead to function and aesthetic sequelae thus requiring the use of modern techniques of reconstructive surgery. The authors describe the diagnosis, treatment and follow-up of large lingual SCC case using a DIEP free flap reconstruction according to an original technique developed in the department. Given the characteristics of patients with SCC (a high proportion of women between 20 and 40 years old) and its inherent qualities (low morbidity of the donor site, volume delivered and excellent plasticity), the fascio-cutaneous free flap type "DIEP" "taken according to the design of the" Cathedral triptych seems to be a viable choice among the range of reconstruction solutions.

Is it possible to calculate surface areas of intraoral structures from preoperative CT scan?

Microsurgical reconstruction of intraoral structures requires accurate planning of flap shape and dimensions. The goal of this study is to describe a method that allows to calculate surfaces of oral structures from preoperative CT-scan in order to determine a precise flap design before the surgery. We created casts of the human mouth from cadavers with a head and neck CT-scan available using an impression material. We digitalized the mouth casts and unwrapped the surfaces of the different structures of the mouth in a bi-dimensional plane in order to measure the area. Furthermore, we measured distances from pre-determined bony landmarks using the CT-scan 3D reconstruction model and we correlated the two type of measurements. We performed a simple regression analysis and afterwards a multivariate analysis using the more statistically correlated measurements. We found a statistical correlation between the surface of the tongue and the surface floor of the mouth with three bone distances that let us to create three mathematical formulas. With those formulas, we can calculate the surfaces of the tongue and the floor of the mouth using simple bony distances that can be easily measured from the head and neck preoperative CT scan. Using standard template's layouts, we can create a precise preoperative flap design in the reconstruction of the tongue and of the floor of the mouth.

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.

[Harvesting technique of chimeric multiple paddles fibular flap for wide oromandibular defects]

Carcinological head and neck reconstruction still remains a challenge due to the volume and varied tissues needed. Large and wide oromandibular defects require, not just the bone but also soft tissues for the pelvilingual reconstruction and therefore, a second free flap may become necessary in addition to a fibular flap. The option of an unique chimeric flap based on the fibular artery and its branches is less known whereas it offers the advantage of a unique flap with bone, muscle and multiple skin paddles, independent of each other. The aim of this technical note is to present step by step the surgical procedure of this chimeric flap and share this method that avoids a second free flap.