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

ABSTRACT

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.

KEYWORDS

Vertical rectus abdominus myocutaneous - VRAM - glossectomy - reconstruction

REFERENCES

• 1 Hirano M, Kuroiwa Y, Tanaka S et al.. Dysphagia following various degree of surgical resection for oral cancer.  Ann Otol Rhinol Laryngol. 1992;  101 138-141
• 2 Zuydam A C, Rogers S N, Brown J S, Vaughan E D, Magennis P. Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma.  Br J Oral Maxillofac Surg. 2000;  38 513-518
• 3 Myers E N. The role of total glossectomy in the management of cancer of the oral cavity.  Otolaryngol Clin North Am. 1972;  5 343-355
• 4 Gehanno P, Guedon C, Barry B, Depondt J, Kebaili C. Advanced carcinoma of the tongue: total glossectomy without total laryngectomy. Review of 80 cases.  Laryngoscope. 1992;  102 1369-1371
• 5 Weber R S, Ohlms L, Bowman J, Jacob R, Goepfert H. Functional results after total or near total glossectomy with laryngeal preservation.  Arch Otolaryngol Head Neck Surg. 1991;  117 512-515
• 6 Razack M S, Sako K, Bakamjian V Y, Shedd D P. Total glossectomy.  Am J Surg. 1983;  146 509-511
• 7 Yamamoto Y, Sugihara T, Furuta Y, Fukuda S. Functional reconstruction of the tongue and deglutition muscles following extensive resection of tongue cancer.  Plast Reconstr Surg. 1998;  102 993-998
• 8 Kiyokawa K, Tai Y, Inoue Y, Tanaga H, Mori K, Nakashima T. Functional reconstruction of swallowing and articulation after total glossectomy without laryngectomy: money pouch-like reconstruction method using rectus abdominis myocutaneous flap.  Plast Reconstr Surg. 1999;  104 2015-2020
• 9 Lyos A T, Evans G R, Perez D, Schusterman M A. Tongue reconstruction: outcomes with the rectus abdominis flap.  Plast Reconstr Surg. 1999;  103 442-447
• 10 Nakatsuka T, Harii K, Yamada A, Asato H, Ebihara S. Versatility of a free inferior rectus abdominis flap for head and neck reconstruction: analysis of 200 cases.  Plast Reconstr Surg. 1994;  93 762-769
• 11 Kimata Y, Sakuraba M, Hishinuma S et al.. Analysis of the relations between the shape of the reconstructed tongue and postoperative functions for subtotal or total glossectomy.  Laryngoscope. 2003;  113 905-990
• 12 Kimata Y, Sakuraba M, Namba Y, Hayashi R, Ebihara S. Functional reconstruction with free flaps following ablation of oropharyngeal cancer.  Int J Clin Oncol. 2005;  10 229-233
• 13 Japan Society for Head and Neck Cancer .General Rules for Clinical and Pathological Studies on Head and Neck Cancer. 2nd Ed. Tokyo; Kinbara 1991: 101
• 14 Baker B M, Fraser A M, Baker C D. Long-term postoperative dysphagia in oral/pharyngeal surgery patients: subjects' perceptions vs. video fluoroscopic observations.  Dysphagia. 1991;  6 11-16
• 15 Washio H. Use of a pterygoid muscle sling to provide glossomimic function after total glossectomy.  Plast Reconstr Surg. 1973;  51 497-500
• 16 Remmert S M, Sommer K D, Majocco A M, Weerda H G. The neurovascular infrahyoid muscle flap: a new method for tongue reconstruction.  Plast Reconstr Surg. 1997;  99 613-618
• 17 Mikaelian D O. Reconstruction of the tongue.  Laryngoscope. 1984;  94 34-37
• 18 Conley J, Sachs M E, Parke R B. The new tongue.  Otolaryngol Head Neck Surg. 1982;  90 58-68
• 19 Robertson M S, Robinson J M, Horsfall R M. A technique of tongue reconstruction following near-total glossectomy.  J Laryngol Otol. 1987;  101 260-265
• 20 Mitrani M, Krespi Y P. Functional restoration after subtotal glossectomy and laryngectomy.  Otolaryngol Head Neck Surg. 1988;  98 5-9
• 21 Haughey B H. Tongue reconstruction: concepts and practice.  Laryngoscope. 1993;  103 1132-1141
• 22 Haughey B H, Fredrickson J M. The latissimus dorsi donor site: current use in head and neck reconstruction.  Arch Otolaryngol Head Neck Surg. 1991;  117 1129-1134
• 23 Cheng N, Shou B, Zheng M, Huang A. Microneurovascular transfer of the tensor fascia lata musculocutaneous flap for reconstruction of the tongue.  Ann Plast Surg. 1994;  33 136-141
• 24 Muldowney J B, Cohen J I, Porto D P, Maisel R H. Oral cavity reconstruction using the free radial forearm flap.  Arch Otolaryngol Head Neck Surg. 1987;  113 1219-1224
• 25 Aviv J E, Keen M S, Rodriguez H P et al.. Bilobed redial forearm free flap for functional reconstruction of near-total glossectomy defects.  Laryngoscope. 1994;  104 893-900
• 26 Urken M L, Biller H F. A new bilobed design for the sensate radial forearm flap to preserve tongue mobility following significant glossectomy.  Arch Otolaryngol Head Neck Surg. 1994;  120 26-31
• 27 Yousif N J, Dzwierzynski W W, Sanger J R, Matloub H S, Campbell B H. The innervated gracilis musculocutaneous flap for total tongue reconstruction.  Plast Reconstr Surg. 1999;  104 916-921
• 28 Wolff K D. Indications for the vastus lateralis flap in oral and maxillofacial surgery.  Br J Oral Maxillofac Surg. 1998;  36 358-364
• 29 Kimata Y, Uchiyama K, Ebihara S et al.. Comparison of innervated and noninnervated free flaps in oral reconstruction.  Plast Reconstr Surg. 1999;  104 1307-1313
• 30 Hayden R E, Deschler D G. Lateral thigh free flap for head and neck reconstruction.  Laryngoscope. 1999;  109 1490-1494
• 31 Matloub H S, Larson D L, Kuhn J G, Yousif N J, Sanger J R. Lateral arm free flap in oral cavity reconstruction: a functional evaluation.  Head Neck. 1989;  11 205-211
• 32 Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction.  Head Neck. 2004;  26 1038-1044
• 33 Salibian A H, Allison G R, Rappaport I, Krugman M E, McMicken B L, Etchepare T L. Total and subtotal glossectomy: function after microvascular reconstruction.  Plast Reconstr Surg. 1990;  85 513-524 , discussion 525–526
• 34 Yu P, Robb G L. Reconstruction for total and near-total glossectomy defects.  Clin Plast Surg. 2005;  32 411-419
• 35 Goode R L. Laryngeal suspension in head and neck surgery.  Laryngoscope. 1976;  86 349-355
• 36 Hillel A D, Goode R L. Lateral laryngeal suspension: a new procedure to minimize swallowing disorders following tongue base reconstruction.  Laryngoscope. 1983;  93 26-31
• 37 Tiwari R M, Greven A J, Karim A B, Snow G B. Total glossectomy: reconstruction and rehabilitation.  J Laryngol Otol. 1989;  103 917-921
• 38 Calcaterra T C. Laryngeal suspension after supraglottic laryngectomy.  Arch Otolaryngol. 1971;  94 306-309
• 39 Salibian A H, Rappaport I, Allison G. Functional oromandibular reconstruction with the microvascular composite groin flap.  Plast Reconstr Surg. 1985;  76 819-828
• 40 Allison G R, Rappaport I, Salibian A H et al.. Adaptive mechanisms of speech and swallowing after combined jaw and tongue reconstruction in long-term survivors.  Am J Surg. 1987;  154 419-422