Total or near total tongue reconstruction is most effectively achieved with large
free flaps in order to manage defects created by relatively large extirpations. Although
when inset as commonly described, the free vertical rectus abdominis myocutaneous
(VRAM) flap functions effectively as a space filler, to recontour the floor of the
mouth and to resurface the lingual aspect of the mandible, this inset (skin to remaining
oral mucosa) obviates a more anatomical reconstruction. The authors described an alternative
technique that allows for semi-dynamic tongue reconstruction, which better approximates
normal anatomy, thereby improving postoperative speech and swallowing, without increasing
aspiration risk.
From 1997 to 2004, 8 patients with oral tongue squamous cell carcinoma underwent total
(7) or subtotal (1) glossectomy with VRAM reconstruction. All patients underwent both
PEG placement and tracheotomy. Floor of mouth reconstruction was achieved with generous
overlapping rectus muscle inset, supported at both the fascial and muscular surfaces
to the inferior mandibular border. Intraorally, the muscle was attached to remaining
lingual mucosa or gingiva. The neotongue, consisting of skin and subcutaneous fat,
was sutured posteriorly to the remaining tongue base, while the other surfaces were
trimmed to size and left unsutured, sitting on underlying musculature. Early endpoints
were assessments of flap survival and complications (fistula, hematoma, infection).
Late endpoints were evaluation of speech, swallowing, aspiration, and PEG/tracheotomy
dependency.
All patients underwent successful free VRAM reconstruction of the oral tongue. Rapidly,
VRAM skin and subcutaneous tissue assumed the palatal arch configuration. Subcutaneous
fat developed uniform granulation tissue within 2 weeks. This was followed by mucosalization
of the granulation tissue and the underlying exposed rectus muscle/fascia. Flap monitoring
was facilitated by exposed tissue; there was no flap loss. There were no fistulae
or hematomas. One lateral neck flap cellulitis resolved with antibiotic treatment.
One year postoperatively, all patients were tolerating ad libitum diets. All patients
regained intelligible speech facilitated by the controllable obturator effect of the
neotongue. No aspiration was evident by either clinical evaluation or video fluoroscopy.
All patients were PEG/tracheotomy free.
Although a static construct in isolation, the neotongue reconstruction described sits
on a mobile base (the mandible) under voluntary control of the patient, thereby permitting
effective obturation against the hard palate and, in turn, effective speech and swallowing.
These advantages arise without increased technical difficulty and at minimal expense
to the patient, offering an improvement to the standard tried and tested oral tongue
reconstruction.