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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.