Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: Functional outcomes

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan

BACKGROUND

There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction.

METHODS

This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence.

RESULTS

Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15.

CONCLUSION

The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Impact of Dynamic Tongue Reconstruction on Sequential Changes of Swallowing Function in Patients Undergoing Total or Near-Total Glossectomy

PURPOSE

This study aimed to compare the effects of motor-innervated free flap on sequential changes of swallowing function in patients undergoing total or near-total glossectomy with laryngeal preservation.

MATERIALS AND METHODS

The medical charts of 21 patients who underwent tongue reconstruction after total or near-total glossectomy between April 2015 and December 2020 were retrospectively reviewed. Patients were divided into groups by reconstruction type: conventional, reconstruction using an anterolateral thigh free flap (n = 11), and dynamic, reconstruction using an anterolateral thigh with innervated vastus lateralis flap (n = 10). Demographics, surgical details, and survival outcomes were investigated. A videofluoroscopic penetration-aspiration scale and functional outcome swallowing scale were analyzed according to postoperative time courses, classified as within 6 months, 6 to 12 months, and after 12 months postoperative. A time-to-event analysis was performed for gastrostomy tube status.

RESULTS

The dynamic group showed improved swallowing outcomes at 6 to 12 months postoperative (dynamic vs conventional group, penetration-aspiration scale: 3 ± 1.51 vs 6 ± 1.63, P = 0.024; functional outcome swallowing scale: 1.89 ± 1.36 vs 4 ± 1.41, P = 0.009). In the multivariate analysis, the dynamic group showed a decreased probability of decompensated swallowing function at 6 to 12 months postoperative (odds ratio, 0.062; 95% confidence interval, 0.004-1.084; P = 0.057). A time-to-event analysis revealed no significant difference in gastrostomy tube status between the dynamic and the conventional group.

CONCLUSIONS

Considering higher mortality in patients subjected to total or near-total glossectomy, dynamic reconstruction with motor-innervated free flap is worth to perform in terms of enhancing the swallowing function within 1-year postoperative period, thereby improving the quality of life.

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.

Tissue Transfer After Tongue Resection: Micro-Vascular Reconstruction Using Radial Artery Free Flap versus Reconstruction by Split Thickness Skin Graft in T2 Lesions of Tongue Carcinoma

To compare postoperative complications, functional rehabilitation, surgical outcomes of the radial artery forearm free flap (RAFFF) and split thickness skin graft (STSG) reconstruction of postsurgical defect in T2 lesions of cancer oral cavity. Observational Prospective comparative study. Academic tertiary referral centre. In our study of forty four patients, after tumour resection, half underwent reconstruction using RAFFF (Group I) and another half by STSG (Group II). All of the patients were followed postoperatively to determine and compare their functional outcomes related to donor site and recipient site complications, speech, deglutition and mouth opening. The speech intelligibility and deglutition were each assessed using Articulation Handicap Index and Vedio-fluoroscopy using the Functional oral intake scale. Operative time for STSG reconstruction was shorter at 2.2 ± 0.97 SD hours compared to 5.9 ± 1.24 SD hours for RAFFF reconstruction. Hospital stay was 8.3 ± 1.19 SD days for STSG patients and 12.6 ± 1.7 SD days for RAFFF patients. The functional outcomes of speech quality and swallowing were near comparable in both groups but the donor site complications were significant in the RAFFF group. Operative time, hospital stay and donor site complications are both significantly reduced with the STSG as opposed to RAFF. Functional and oncologic results of both methods are near comparable. To conclude, STSG can be used for reconstruction of the post-surgical defects in T2 lesions of the tongue.

Assessment of Speech and Deglutition in Patients with Carcinoma Tongue Post Radial Forearm Free Flap Cover

Over the past 30 years, the introduction of reconstructive techniques incorporating microvascular free tissue transfer has transformed the quality of life of patients undergoing head and neck surgery.The free forearm flap was first described for head and neck reconstruction by Yang in 1981 when he used this flap to reconstruct a neck defect secondary to a burn scar contracture.In this retrospective cohort study, we have evaluated patients who underwent reconstruction of hemiglossectomy defect with radial forearm free flap for malignancy of tongue, from year 2018 to 2020, with reference to deglutition and speech.As per the data obtained, 41.7% and 50% of the patients had achieved excellently intelligible speech and moderately intelligible speech respectively whereas only 8.3% had poorly intelligible speech. On evaluation of post operative swallowing, 83.4% of the patients had excellent swallowing score and the remaining 16.6% had moderate and poor swallowing score.Hence, reconstruction of hemiglossectomy defects with radial forearm free flap is an excellent method to restore the functional outcomes in speech and deglutition.

Functional Outcomes After Surgical Resection of Tongue Cancer; A Comparative Study Between Primary Closure, Secondary Intention Healing and Flap Reconstruction

The purpose of the study was to assess and compare the quality of speech and swallowing between three reconstruction options (primary closure-group A, secondary intention healing-group B and flap reconstruction-group C), in small to moderate sized onco-surgical defects of oral tongue. 47 patients fulfilled the eligibility criteria during the study period, of which, 15 belonged to group A, 16 belonged to group B, 16 were in group C. Speech and swallowing assessment was done using Speech Intelligibility Assessment score and MD Anderson Dysphagia Inventory, respectively. The above tests were administered pre-operatively, 1 month and 6 months post-operativey in all the study participants. The average scores of speech intelligibility at 1 month were 66.13% (±19.96), 70.04% (±12.28) and 37.31% (±11.29) for groups A, B and C respectively. Similarly, average long term scores for speech intelligibility in these three groups were 72.7% (±17.72), 83.3% (±12.78) and 52.8% (±11.74) respectively. With regards to swallowing the composite scores at 1 month were 73.67 (±13.69), 68.31 (±16.06) and 41.81 (±5.44), and at 6 months were 83.2 (±10.24), 79.31 (±12.29) and 57.88 (±7.37), respectively for groups A, B and C. All the differences were statistically significant (p < 0.05). Healing by secondary intention offered the best functional outcome in terms of speech intelligibility, and primary closure offered best swallowing outcomes in operated cases of oral tongue. This trial has been registered with the Clinical Trials Registry-India in December 2018 (CTRI Reg. No: CTRI/2018/12/016803).

Novel computer-aided reconstruction of soft tissue defects following resection of oral and oropharyngeal squamous cell carcinoma

Background

Reconstruction of soft tissue defects following surgical tumor resection is important for quality of life in cancer patients with oral and oropharyngeal squamous cell carcinoma (SCC). This study presents a novel computer-aided reconstruction of soft tissue (CARST) technology employed with these patients.

Methods

We first described the CARST technology in detail in a report of a 34-year-old male patient with locally invasive right-sided tongue SCC following a nearly total glossectomy and reported the postoperative outcomes. This digital technology was applied to construct a 3D model from CT images, which was used to delineate surgical resection boundaries and design a personalized reconstruction of the soft tissue defect. A nonuniform rational B-spline (NURBS) was generated and applied to transform the 3D model into a 2D flap-cutting guide printed out using a 3D printer. We then reported a case-series study on oral and oropharyngeal SCC patients who were randomly assigned to receive the CARST (n = 15) or a traditional soft tissue reconstruction (n = 15). Clinicopathological features and short- and long-term postoperative outcomes between the two groups were compared.

Results

The patient with the tongue SCC had a successful CARST following surgical tumor resection without any complications. His speech and swallowing functions recovered well after surgery and he experienced no significant changes to his appearance following recovery. There was no recurrence within a 3-year follow-up period. Results of the case-series study showed that the CARST group had significantly shorter operative and post-operation hospital-stay time, a higher flap utilization rate, and a trend of less and milder postoperative complications, and they experienced no significant difference in intraoperative blood loss and long-term outcomes compared to the traditional group.

Conclusion

CARST is a safer and more efficient personalized technology of soft tissue reconstruction following surgical tumor resection in patients with oral and oropharyngeal SCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02654-7.

Oral Cavity Reconstruction over a 30-Year Period at a Dedicated Tertiary Head and Neck Cancer Centre

There are around 2,500 new cases of oral cavity squamous cell carcinoma (OSCC) reported yearly within Australia. Resection often leads to substantial defects, requiring complex reconstruction. The aim of this study was to examine how reconstruction at a dedicated head and neck cancer unit has evolved over a 30-year period. A retrospective review was conducted of all OSCC carcinoma cases performed from 1988 to 2017. Data was analysed in six-time periods; pre-1995, 1995–1999, 2000–2004, 2005–2009, 2010–2014, and 2015 and above. A total of 903 patients were identified, of which 56.1% (n = 507) underwent free flap reconstruction including 426 (84.0%) soft tissue free flaps (STFF) and 81 (16.0%) bony free flaps (BFF). STFF usage remained stable over time. The radial forearm was the most common free flap but declined over time with increasing use of the anterolateral thigh flap. The number of BFF increased from 5.0% before 1995 to 20.4% in 1995–2015. The tongue was the most common subsite, followed by the floor of mouth. Free flaps were utilised in more than 50% of OSCC reconstructions at each time period. Over time, the proportion of different STFF evolved towards increased use of the ALT flap and BFF within our institution. Level of evidence: Level four.

Muscle Regeneration of the Tongue: A review of current clinical and regenerative research strategies

Various abnormalities of the tongue, including cancers, commonly require surgical removal to sequester growth and metastasis. However, even minor resections can affect functional outcomes such as speech and swallowing, thereby reducing quality of life. Surgical resections alone create volumetric muscle loss whereby muscle tissue cannot self-regenerate within the tongue. In these cases, the tongue is reconstructed typically in the form of autologous skin flaps. However, flap reconstruction has many limitations and unfortunately is the primary option for oral and reconstructive surgeons to treat tongue defects. The alternative, but yet undeveloped strategy for tongue reconstruction is regenerative medicine, which widely focuses on building new organs with stem cells. Regenerative medicine has successfully treated many tissues, but research has inadequately addressed the tongue as a vital organ in need of tissue engineering. In this review, we address the current standard for tongue reconstruction, the cellular mechanisms of muscle cell development, and the stem cell studies that have attempted muscle engineering within the tongue. Until now, no review has focused on engineering the tongue with regenerative medicine, which could guide innovative strategies for tongue reconstruction.

Resuming Oral Feeding in Patients With Oral Squamous Cell Carcinoma With Free Anterolateral Thigh Flap Reconstruction

BACKGROUND

Quality of life and functional improvement have emerged as important goals for patients with oncologic disease. For patients with head and neck cancer, free anterolateral thigh (ALT) flaps serve as reliable reconstruction and provide functional restoration. Nevertheless, factors affecting the resumption of oral feeding are rarely described. This study aimed to evaluate and compare the functional outcomes of oral feeding for patients with different oncologic defect patterns and reconstructive ALT flap designs.

METHODS

We retrospectively reviewed patients with head and neck cancer undergoing oncologic ablation and free ALT reconstruction between January 2016 and April 2018 at National Taiwan University Hospital. Patients were categorized into 2 groups as through-and-through (T&T) and non-through-and-through (non-T&T) according to the defect pattern. We further subgrouped T&T patients into lip resection/lip sparing according to lip involvement. Reconstructive ALT flaps were of 2 designs, folded (F-ALT) and chimeric (C-ALT). Outcomes of oral feeding were analyzed using descriptive statistics, and differences between groups were compared using the Student t test.

RESULTS

We identified 233 patients who received oncologic ablation and free ALT flap reconstruction. There was no significant difference in functional recovery between the T&T and non-T&T groups (81.2% vs 73%, P = 0.137). However, among patients who succeeded in resuming oral feeding, lip-sparing patients had better functional recovery in terms of early oral feeding within 6 months and nasogastric tube removal compared with lip-resection patients (100% vs 83.3%, P = 0.001). Moreover, the F-ALT design resulted in a higher success rate in resuming oral feeding compared with the C-ALT design (90.5% vs 54.6%, P = 0.032).

CONCLUSIONS

Patients with head and neck cancer with T&T defects were associated with higher rates of secondary flap revision and a trend of delayed oral feeding. In the long term, improved oral feeding outcome with the F-ALT design was observed compared with the C-ALT design in the specific group with T&T defect.

The Functional & Quality of Life Outcomes of Total Glossectomy with Laryngeal Preservation

BACKGROUND

The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP).

OBJECTIVE

To examine prospectively collected objective, self-reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction.

METHODS

Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre- and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI).

RESULTS

All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P < .001) scores. There was no significant reduction in SHI or total MDADI scores. All patients maintained their QOL in the post-treatment time frame. There was no relationship between free-flap type and outcome.

CONCLUSION

Total glossectomy with laryngeal sparing and free flap reconstruction results in significant reduction in objective functional measurements, but patients report stable functional and quality of life outcomes after treatment.

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.

How to select candidates for microvascular head and neck reconstruction in the elderly? Predictive factors of postoperative outcomes

INTRODUCTION

The proportion of elderly patients with head and neck cancer is increasing. However, predictive factors of postoperative outcomes are insufficiently explored in this population. In this study, we aimed to determine predictive factors of postoperative outcomes in elderly patients undergoing head and neck free-flap reconstructive surgery in order to determine criteria on which patient selection could be based.

METHODS

All patients aged 65 years or over who underwent head and neck free-flap reconstructive surgery at our institution, between 2000 and 2016, were included in this retrospective study. Predictive factors of postoperative outcomes were investigated in uni- and multivariate analysis.

RESULTS

Two-hundred patients were included in the study. Older age (>70, >75 or > 80 yrs) had no significant impact on postoperative outcomes. Free flap failure local and general complications rates were 11%, 34% and 43%, respectively. Oromandibular reconstruction (p = 0.04) was significantly associated with free flap failure and salvage surgery (p = 0.04) with local complications. A high comorbidity level (Charlson Comorbidity Index score ≥ 4; p = 0.02) was associated with a higher risk of general complications. A G8 (Geriatric 8 questionnaire) score < 15 (p = 0.004), a high comorbidity level (Kaplan-Feinstein Index score ≥ 2; p = 0.04) and oromandibular reconstruction (p = 0.04) were associated with poor swallowing function at 6 months.

CONCLUSION

Head and neck free flap reconstruction should be offered to fit (G8 score ≥ 15) elderly patients without severe comorbidities (KFI < 2 or CCI < 4), particularly when oral/pharyngeal soft-tissue reconstruction is planned.

Prognostic factors associated with achieving total oral diet after glossectomy with microvascular free tissue transfer reconstruction

OBJECTIVE

Primary surgery followed by adjuvant therapy is the current standard of care in the multidisciplinary management of squamous cell carcinoma (SCC) of the oral tongue. Additionally, salvage glossectomy is used to treat recurrent base of tongue SCC. Microvascular free tissue transfer reconstruction (MVFTT) is utilized to maximize functional outcomes such as swallowing. We sought to identify prognostic factors related to achievement of a total oral diet in patients that underwent glossectomy with MVFTT.

METHODS

Retrospective review at a tertiary care center from 2010 to 2015.

RESULTS

200 patients (69% male, mean age 60 years) met inclusion criteria. Extent of glossectomy was categorized as partial or hemiglossectomy (39%), tongue base resection with or without hemi-oral glossectomy (23%), composite resection with mandibulectomy (18%), and subtotal or total glossectomy (21%). Flap success rate was 96%. Median follow-up time was 14  months. A total oral diet was achieved by 49% of patients with median time to achievement of 31  days (IQR 9-209). Multivariate analysis identified body mass index  < 25 kg/m2, prior radiation therapy, adjuvant chemoradiation, and resection requiring subtotal or total glossectomy or concurrent mandibulectomy as independent risk factors for worse total oral diet achievement.

CONCLUSION

Swallowing dysfunction represents a significant morbidity following glossectomy in the treatment of SCC. High BMI, smaller resection fields, and absence of prior radiation therapy or adjuvant chemoradiotherapy correlated with improved likelihood of obtaining a total oral diet. Patients should be appropriately counseled of this risk with emphasis placed on aggressive swallow rehabilitation in the post- treatment setting.

Free-Flap Reconstruction of the Tongue

The tongue is paramount to natural speech and swallowing, and good tongue function is important in the overall quality of life. Autologous free-flap reconstruction of the tongue after glossectomy allows for adequate speech, swallow, and quality-of-life outcomes in a majority of patients. Herein, the authors review autologous free-flap reconstruction of the tongue with a focus on different flap options, speech and swallow outcomes, quality-of-life outcomes, and factors that affect how patients perform after tongue reconstruction.

Total Glossectomy With Free Flap Reconstruction: Twenty-Year Experience at a Tertiary Medical Center

OBJECTIVES/HYPOTHESIS

To characterize the demographics, clinicopathologic characteristics, and treatment and reconstructive outcomes of patients who underwent total glossectomy STUDY DESIGN: Retrospective chart review at an academic tertiary-care medical center.

METHODS

All patients who had undergone total glossectomy (as an individual procedure or as part of a more extensive resection) between January 1, 1995 and December 31, 2014 were included in the analysis. Patient characteristics and clinical outcomes were reviewed.

RESULTS

Forty-eight patients underwent total glossectomy for oral tongue and base of tongue cancer. The mean age of the patients was 56 (range, 29-92 years). History of tobacco and heavy alcohol use was found in 76% and 11% of patients, respectively. The majority of patients had advanced cancer (91.7% at stage IV), and 60.4% had salvage therapy for recurrent disease. T4 disease comprised 81% of patients. Sixty percent had clinical or radiographic evidence of nodal metastasis. Reconstruction of the defect was performed with free flaps from the rectus abdominus (40%), fibula (25%), anterolateral thigh (23%), and other donor tissues. One- and 5-year survival rates were 42% and 26%, with locoregional and distant recurrence reported at 36% and 25%, respectively.

CONCLUSIONS

Total glossectomy for oncologic control is most commonly performed in patients who have stage IV cancers. Despite high reconstructive success rates, the likelihood of locoregional and distance recurrence was high. Most patients can communicate intelligibly and achieve decannulation, but swallowing outcomes remain guarded, especially considering previous irradiation and resection of the base of tongue.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1087-1092, 2019.

Progressive functional improvement in hemiglossectomy defects reconstructed with radial forearm free flap at 6-months

OBJECTIVE

The purposes of the study was to evaluate for the functional improvement of outcomes of patients undergoing surgical management for tongue cancer at varying periods after surgery.

DESIGN

Case series with intervention.

PARTICIPANTS

Thirty consecutive patients, from 2011 to 2015, with carcinoma of the tongue undergoing surgical resection and reconstruction with a radial forearm free flap.

MAIN MEASURES

The Speech Intelligibility Test (SIT) is used for objective evaluation of speech function. The 7-point ordinal scale Functional Oral Intake Score (FOIS) was used to estimate the swallowing function.

RESULTS

The patients included were 25 men and 5 women with a mean age of 50.4 years (range - 27-65). All tumors were squamous cell carcinomas and all patients underwent a hemiglossectomy. There were two complete flap failures, with a resultant flap success rate of 93.3%. The initial mean speech intelligibility scores at 1-month increased from 72.3 ± 0.2 to 77.7 ± 8.9 at 6-months after surgery (p = 0.05). Similarly, the mean score of swallowing function improved from 6.1 at 1-month to 6.8 at 6-months after surgery (p = 0.05).

CONCLUSION

Reconstruction of hemiglossectomy defects with a radial forearm free flap offers functional benefits in speech and deglutition that demonstrate progressive improvement when 1- and 6-month post-surgical assessments are compared.

Anterior lateral thigh flap for buccal mucosal defect after resection of buccal cancer

Objective

To preserve oral function after buccal cancer resection, a free anterior lateral thigh flap (ALTF) was used to cover the buccal mucosal defect.

Study Design and Setting

Nine patients who underwent primary surgical treatment between June 2005 and September 2006 for buccal cancer were enrolled in this study. An ALTF was used to repair the defect immediately after tumor resection. Oral function, including mouth-opening width, oral intake, and teeth cleaning, were compared pre- and postoperatively.

Results

No difference was observed in the mouth-opening width between that preoperatively and three months postoperatively ( P = 0.54). The oral intake and teeth cleaning also remained unchanged three months postoperatively.

Conclusion

Repair of a buccal mucosa defect with a free anterior lateral thigh flap is a good alternative for selected patients who undergo resection of buccal cancer; oral function is likely to be preserved.

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.

Flap selection and functional outcomes in total glossectomy with laryngeal preservation

OBJECTIVE

Reconstruction of total glossectomy defects has been revolutionized by the popularity of free flap use in the head and neck. Challenging defects can be addressed with a variety of different free and pedicled flaps. The purpose of this study is to review our method of flap selection in cases of total glossectomy defects with laryngeal preservation, with an emphasis on the variations of these defects and patient body habitus.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care referral center.

SUBJECTS AND METHODS

All patients undergoing total glossectomy with laryngeal preservation (TGLP) by the senior author (YD) from September 1997 to May 2012. Objective data regarding patient demographics, existing defect, method of reconstruction, adjuvant treatment, operative details, outcomes, and complications were recorded. Both means and frequency of prolonged tracheostomy or gastrostomy tube were used to assess outcomes.

RESULTS

One hundred and three patients were identified. Ninety-four met inclusion criteria. All patients were T3 or T4 stage tumors. Mean follow-up was 3.4 years. Fifty-nine patients (62%) underwent free flap reconstruction while the remaining 35 (37%) were treated with a pedicled pectoralis myocutaneous flap. Tracheostomy decannulation and gastrostomy tube removal rates were 84% and 29%, respectively. No patients were converted to total laryngectomy.

CONCLUSION

Optimal reconstruction of TGLP defects may be accomplished with either pedicled or free-tissue flap reconstruction. Selecting an ideal flap for reconstruction of total glossectomy defects should be patient specific and based on matching donor flap bulk. This treatment approach demonstrates high tracheostomy and gastric tube independence.

Secondary Onlay Free Flap Reconstruction of Glossectomy Defects following Initial Successful Flap Restoration

Patients who undergo tongue reconstruction over time may develop gradual worsening of dysarthria and dysphagia secondary to flap atrophy. At our institution, these patients undergo a secondary flap onlay procedure for augmentation of the neotongue. We review a total of 11 patients with total glossectomy defect who underwent secondary tongue augmentation with secondary onlay free flap consisting of radial forearm free flap (n = 6) and rectus free flap (n = 5). There was improvement in swallowing in 7 of 11 patients. Five (45.4%) patients achieved gastric tube independence. Seven (63.6%) patients achieved a varying degree of oral intake. All patients achieved tracheostomy independence. Dysarthria was improved in all patients. There were no flap failures. Therefore, a secondary onlay flap technique is feasible and may improve dysphagia and dysarthria to achieve gastric tube and tracheostomy independence in total glossectomy patients with delayed tongue atrophy.

Total glossectomy with laryngeal preservation and free flap reconstruction: objective functional outcomes and systematic review of the literature

OBJECTIVE

Advanced tongue cancer is a devastating diagnosis with potential for significant morbidity after treatment. This is especially true for patients undergoing total glossectomy with laryngeal preservation (TGLP), free flap reconstruction and adjuvant radiotherapy. The goals of this study were to: 1) determine long-term objective functional and quality of life outcomes, 2) investigate the influence of rehabilitation on functional recovery and 3) determine swallowing ability in patients with TGLP.

STUDY DESIGN

Prospective cohort study and systematic review of the literature.

METHODS

Functional outcomes data were collected from 2000-2010. Outcomes were measured pre- and 12 months post-surgery and included: gastrostomy-tube (G-Tube) rates, swallowing transit times on video fluoroscopic swallowing studies, speech intelligibility and EORTC-H&N 35 quality of life scores. A systematic review of the literature was conducted to determine comprehensive long term G-Tube rates.

RESULTS

Twelve patients were included and eight were still living at 12 months post-surgery. Fifty percent of patients in this study and 24% with systematic review used G-Tubes at 1 year post-surgery. Patients who could swallow did not aspirate, but more than doubled swallowing transit times. Spoken sentence intelligibility averaged 66% and mean quality of life scores improved 8.9 points 12 months post-surgery. Patients who attended >80% of swallowing and speech rehabilitation sessions demonstrated superior swallowing and speech functional outcomes.

CONCLUSIONS

Although a potentially morbid treatment, TGLP and free flap reconstruction can provide good swallowing and speech outcomes as well as meaningful long-term quality of life. Regular attendance of rehabilitation sessions is imperative to optimize functional outcomes.

[Tongue reconstruction with a bilateral infrahyoid flap innervated by Ansa Cervicalis after total glossectomy]

INTRODUCTION

Reconstruction after total glossectomy remains a functional challenge. It must provide a large volume to ensure adequate phonation and swallowing. We present the larynx sparing bilateral infrahyoid flap reconstruction procedure after total glossectomy.

PATIENTS AND METHOD

Three patients managed for an epidermoid carcinoma of the tongue, classified T4N0, underwent total glossectomy. The tongue was reconstructed with a bilateral infrahyoid flap pedicled on two superior thyroid arteries and innervated by Ansa Cervicalis.

RESULTS

Oral food intake was resumed after 8 to 20 days. No false route was observed. The muscular flap mobility was clinically satisfactory. It was assessed by EMG in one case. Esophageal transit confirmed the absence of stasis and false route for one patient.

DISCUSSION

This short series proves the feasibility of bilateral innervated and pedicled infrahyoid flap procedure. It is an alternative to volumetric and functional reconstruction after total glossectomy. The indications are rare and restricted to patients without IIa nodal region invasion. Our results are still limited and need to be confirmed by a larger series and by a more systematic assessment.

Oral sensation and function: a comparison of patients with innervated radial forearm free flap reconstruction to healthy matched controls

BACKGROUND

Limited evidence exists for the use of innervated radial forearm free flap (RFFF) reconstruction of hemiglossectomy defects. This study reports on sensation, mastication, and speech outcomes for patients with innervated RFFF reconstruction of the anterior two-thirds of the tongue.

METHODS

Sensation, mastication, and speech intelligibility were assessed in 8 patients and age- and sex-matched controls.

RESULTS

Sensation of intact tongue tissue after reconstruction of the hemitongue did not differ from controls. Although some sensory ability was restored to patients' reconstructed tongue, differences existed between the patient group and controls. However, whole mouth sensations resulted in similar sensory ability as controls. Whereas patients demonstrated adequate masticatory and speech ability, differences existed between patients and controls.

CONCLUSION

Although some sensory ability is preserved in patients who have had tongue reconstruction with an innervated RFFF, functional outcomes such as masticatory ability and speech intelligibility may be affected in some patients.

Double Bilobed Radial Forearm Free Flap for Anterior Tongue and Floor-of-Mouth Reconstruction

We describe what is, to the best of our knowledge, the first use of a double bilobed radial forearm free flap in reconstructive surgery of the tongue and floor of the mouth following bilateral tumor resection. Our patient was a 78-year-old man who had experienced tumor recurrence in the anterior floor of the mouth after previous resection and radiotherapy. Eleven weeks postoperatively, the patient could extend his tongue to his hard palate and past his mandibular alveolus anteriorly. Within 6 months, he was able to tolerate an oral diet of soft food and exhibited understandable speech quality. Although the use of a single bilobed radial forearm flap is widely used after hemiglossectomy, our double bilobed modification extends this technique to anterior tongue and floor-of-mouth defects. This technique provides adequate bulk while allowing for depth of a ventral sulcus that will minimize tethering of the tongue and reduce oral incompetence. We recommend that this technique be included in the armamentarium of any reconstructive head and neck cancer surgeon.

Tongue reconstruction: recent advances

PURPOSE OF REVIEW

To examine the recent literature concerning advances in tongue reconstruction after tumor resection.

RECENT FINDINGS

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.

SUMMARY

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.

Swallowing Outcomes After Microvascular Head and Neck Reconstruction: A Prospective Review of 191 Cases

BACKGROUND

The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomic reconstructions to be performed and, in turn, has improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic.

METHODS

The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with four specific microvascular flaps based on their surgical defect, and postoperative swallowing outcomes were evaluated and recorded on a prospectively maintained database. Pre- and postoperative swallowing was graded on an ordinal scale. Data were simultaneously collected on the precise anatomic ablative defect in each patient, subdividing the head and neck into 16 subsites. The data were analyzed using a multivariate analysis accounting for comorbid factors, type of flap used, and subsite of defect.

RESULTS

The findings are summarized as follows. There were no flap failures. The percent of patients who were able to swallow and maintain an exclusively oral diet postoperatively was 78.5%. Only 16.8% were unable to have an oral diet (NPO) and dependent on a gastric tube (G-tube) for feeding. The factors that predicted an inability to swallow include tongue resection, preoperative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects, regardless of size, had excellent long-term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet.

CONCLUSIONS

In summary, we report excellent postoperative swallowing outcomes after microvascular reconstructions at our institution that compare favorably with outcomes with pedicled flaps and historic controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult subsites to reconstruct were tongue defects, which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preoperative radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain swallowing function. These data will hopefully support numerous previous studies that have established the use of microvascular reconstruction as standard of care for ablative surgical defects in the head and neck.