DOI: 10.1097/PRS.0b013e31817d5f12
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PMID: 18626322
Issn Print: 0032-1052
Publication Date: 2008/08/01
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Excerpt
Total or subtotal glossectomy for advanced oral cavity carcinoma commonly leaves patients with significant functional deficits of speech and swallowing. In addition, these patients are at significant risk of postglossectomy aspiration. The free vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the primary workhorse for tongue reconstruction following large resections; however, the standard free VRAM flap reconstruction has produced inconsistent results with regard to postoperative speech and swallowing.1 We describe a simple technical modification that better recreates the native anatomy. Nine consecutive patients have thus far undergone this procedure and have been followed for at least 1 year.
All patients underwent percutaneous endoscopic gastrostomy tube placement and tracheotomy. During the ablative procedure, a second team harvested the contralateral VRAM flap. The recipient vessels were prepared; usually, the ipsilateral facial artery and common facial vein were used. After revascularization, the neotongue, consisting of skin and subcutaneous fat, was sutured posteriorly to the remaining tongue base. When the base of the tongue was resected, inset was to the remaining hypopharynx, and hyoid suspension was performed to maintain the relationship between the larynx and the neotongue. The floor of the mouth was reconstructed with an overlapping rectus muscle inset, supported at both the fascial and muscular surfaces to the inferior mandibular border (to periosteum or drill holes) (Fig. 1). Intraorally, muscle was attached to the remaining lingual mucosa or gingiva. The mandible, which was always preplated before mandibular split, was then closed. The remaining skin and subcutaneous fat were trimmed to size and left unsutured, thus sitting on underlying musculature to form a tongue-like protrusion (Fig. 2).
The VRAM skin and subcutaneous tissue assumed the palatal arch configuration, and within 2 weeks, subcutaneous fat developed uniform granulation tissue. This was followed by mucosalization of the granulation tissue and the underlying exposed rectus muscle and fascia.
Complications have been limited to one episode of cellulitis. All patients regained intelligible speech. One year postoperatively, all patients achieved weight maintenance and were tolerating unrestricted diets consisting of soft foods or greater consistency. No aspiration was evident by either clinical evaluation or video fluoroscopy. All patients were gastrostomy tube and tracheotomy free.
Glossectomy reconstruction with the VRAM flap has evolved with efforts to create a more functional tongue. Principally, maintenance of the neotongue bulk and convexity has produced improved function.2 Attempts to achieve this include flap neurotization3 and the creation of oversized flaps.4
We describe a novel alternative to the standard method of glossectomy reconstruction that confers the advantages of creating neotongue bulk and convexity. By allowing the skin and soft tissue to remain elevated and unsutured to the oral mucosa, a protuberant, more anatomically correct tongue is created. This design permits obturation against the palate, resulting in more effective speech and swallowing (see Video, Supplemental Digital Content 1, which shows a 63-year-old man with a T4N2M0 lesion of the oral tongue who underwent total glossectomy and VRAM reconstruction, http://links.lww.com/A453). In addition, although the reconstructive method is static, it provides a neotongue that sits on the mandible and acts as a mobile base under voluntary control allowing for dynamic motion. This VRAM modification is easy to execute and maximizes functional outcome.
