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.






Publication: Ear, Nose & Throat Journal
Author: Ko, Alvin B
Date published: April 1, 2010

Introduction

Treating cancer of the tongue is fraught with lifechanging significance, as the organ plays a critical role in everyday activities, including swallowing, speaking, and taste. Squamous cell carcinoma is the most common histology, typically presenting in 50- to 60-year-old men with a history of tobacco or alcohol use.1 The posterolateral aspect is the most common site, although 20% of lesions occur in the anterolateral or ventral tongue.1

Reconstruction of the tongue after tumor extirpation primarily focuses on maximizing function, Urken and Biller describe a bilobed radial forearm flap for tongue reconstruction, separating the neotongue from the floor of the mouth and thereby facilitating tongue motion and function.2 All patients in the original series, however, underwent unilateral partial glossectomies. We introduce a double bilobed modification for a patient requiring reconstruction after bilateral anterior partial glossectomy.

Technique

The procedure described here was performed in a 78year-old man with recurrent squamous cell carcinoma in the anterior floor of the mouth after previous resection and radiation therapy. Interdisciplinary tumor board evaluation recommended surgical salvage.

Triple endoscopy showed a bilateral lesion in the anterior floor of the mouth that was adjacent to but not involving the mandible; the lesion was larger on the right side than on the left. Submucosal extension of the left lateral ventral tongue was identified intraoperatively.

After percutaneous endoscopic gastrostomy tube placement and tracheotomy, a standard midline mandibuloto my approach was utilized, with cervical incisions extending access to the neck bilaterally. Bilateral neck exploration was performed to identify a suitable donor vessel for microvascular anastomosis.

A marginal mandibulectomy extending from left of midline to right midbody was performed in continuity with the tumor. The resultant defect included the anterior mandibular alveolus, the anterior half of the oral tongue, and the bilateral floor of the mouth, extending posteriorly to the bilateral plica sublingualis (figure 1). Resection margins were verified as negative on frozen section.

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A double bilobed radial forearm flap was designed and harvested from the patient's left (nondominant) forearm (figure 2). The central epithelium was then denuded, allowing the remaining intervening subcutaneous tissue between the bilobed skin flaps to facilitate independent mobility of each lobe. The lateral antebrachial cutaneous nerve was carefully preserved. The proximal donor site was closed in layers, and the distal donor defect was covered with a split-thickness skin graft harvested from the anterior thigh.

In the oral cavity, the bilobed flaps were positioned to allow the larger opposing lobes to be sutured together using 3-0 absorbable sutures in horizontal mattress stitches, forming an anterior tongue. This was attached to the existing tongue in a layered fashion using 3-0 absorbable sutures. Then, a sulcus was created by folding the flap and using the smaller opposing lobes to reconstruct the floor of the mouth. The edges of the mandible were contoured using a pineapple bur prior to watertight closure of the radial forearm flap to the native floor-of-mouth mucosal remnant.

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The lower lip and external incisions were then repaired in a layered fashion with resuspension of the soft-tissue envelope to the mandibular symphysis (figure 3). The microvascular anastomosis between the radial and facial arteries was performed using 9-0 nylon sutures, while the cephalic and internal jugular veins were connected via an end-to-side anastomosis. Neurorrhaphy between the lateral antebrachial cutaneous nerve and the lingual stump was completed under a microscope using 10-0 nylon sutures. After adequate perfusion was confirmed, drains were placed and the neck was closed in layers.

The patient's postoperative hospital course was unremarkable. After discharge, he showed good healing of his wounds; 1 1 weeks after his surgery, he could extend his tongue to his hard palate and, anteriorly, past his mandibular alveolus (figure 4). Within 6 months of his reconstruction, he was able to tolerate an oral diet of soft food and exhibited easily understandable speech quality. He has not yet reported sensation in his neotongue, but the full extent of his recovery was unfortunately interrupted by tumor recurrence in his remaining tongue, as well as new metastatic lesions in his lungs. The patient deferred further treatment and was referred to hospice.

Discussion

For reconstructing most partial glossectomy defects, thin fasciocutaneous flaps, such as those harvested from the radial forearm or anterior thigh, are commonly used because these options maximize tongue mobility and minimize tethering.3 The bilobed radial forearm flap is widely accepted and used for tongue reconstruction but, to the best of our knowledge, ours is the first report in the English literature of the use of a double bilobed flap design for this purpose. The double bilobed design theoretically offers the same mobility advantages afforded by the single bilobed design but allows for reconstruction of a larger defect: the bilateral anterior tongue.

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Our technique provides adequate bulk while allowing for depth of a ventral sulcus that will minimize tethering of the tongue and reduce oral incompetence by creating a neovestibule. Also, the reliable achievement of a sensate flap seen in the single-bilobed design - a feature that has traditionally been thought to improve function - should theoretically be preserved in our double-bilobed design. Uwiera et al reported a series of 14 patients in whom single bilobed radial forearm flap reconstruction after hemiglossectomy resulted in equal pre- and postoperative speech intelligibility, as well as decreased aspiration risk, regardless of flap sensation.4

The recovery window for our patient is still technically open. Kuriakose et al reported that all 1 7 patients in their series of radial forearm free flap tongue reconstructions recovered sensation within 8 months.5 However, our patient's dermal metastases may prevent complete sensation recovery.

In the reconstruction of defects larger than that described here, Yu and Robb suggest using an anterior thigh fasciocutaneous flap because it provides more bulk than the radial forearm flap.3 This, in turn, facilitates the tongue-palate contact that is critically important for speech, swallowing, and saliva-flow routing to reduce aspiration. Their series of 2 1 patients who underwent anterior thigh flap reconstruction of total or near- total glossectomy attained speech with multiple errors but intelligible to listeners not familiar with thepatient.Their patients with sensate flaps achieved a soft diet on average, but their patients with insensate flaps only averaged a diet between liquid and part oral/part nonoral.3

In our patient, the anterior thigh flap would have been a reasonable option. However, Chien et al showed no statistical differences in achieving intelligible speech, level of aspiration, and level of diet attained between patients reconstructed with either a radial forearm flap or an anterior thigh flap after near-total or total glossectomy.6

In summary, we describe a novel double bilobed radial forearm flap design for bilateral anterior tongue and floor-of-mouth reconstruction that results in good speech and attainment of oral diet. This result is comparable to other reconstructive options available for this type of defect and should be a part of the armamentarium of any reconstructive head and neck cancer surgeon.

References

1. Wein RO, Weber RS. Malignant neoplasms of the oral cavity. In: Cummings CW, Wein RO, Weber RS, et al (eds). Otolaryngology Head and Neck Surgery, 4th ed. Philadelphia: Mosby; 2005: Chapter 70.

2. Urken ML, Biller HF. A new bilobed design for the sensate radial forearm flap to preserve tongue mobility following significant glossectomy. Arch Otolaryngol Head Neck Surg 1994;1201):26-31.

3. Yu P, Robb GL. Reconstruction for total and near-total glossectomy defects. Clin Plastic Surg 2005;32(3):41 1-19, vii.

4. Uwiera T, Seikaly H, Rieger J, et al. Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap. I Otolaryngol 2004;33(6):356-9.

5. Kuriakose MA, Loree TR, Spies A, et al. Sensate radial forearm free flaps in tongue reconstruction. Arch Otolaryngol Head Neck Surg 2001;127(12):1463-6.

6. Chien CY, Su CY, Hwang CF, et al. Ablation of advanced tongue or base of tongue cancer and reconstruction with free flap: Functional outcomes. Eur J Surg Oncol 2006;32(3):353-7.

Author affiliation:

Alvin B. Ko, MD; Pierre Lavertu, MD, FRCS, FACS; Rod P. Rezaee, MD

Author affiliation:

From the Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University (Dr. Ko, Dr. Lavertu, and Dr. Rezaee), and Ireland Cancer Center, University Hospitals Case MedicalCenter (Dr. Lavertu and Dr. Rezaee), Cleveland, Ohio.

Corresponding author: Alvin B. Ko, MD, Department of OtolaryngologyHead and Neck Surgery, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106. E-mail: alvin.ko@gmail.com.

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