BEAVERTAIL MODIFICATION OF THE RADIAL FOREARM FREE FLAP IN BASE OF TONGUE RECONSTRUCTION: TECHNIQUE AND FUNCTIONAL OUTCOMES

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1 ORIGINAL ARTICLE BEAVERTAIL MODIFICATION OF THE RADIAL FOREARM FREE FLAP IN BASE OF TONGUE RECONSTRUCTION: TECHNIQUE AND FUNCTIONAL OUTCOMES Hadi Seikaly, MD, FRCSC, 1,2 Jana Rieger, PhD, 2 Daniel O Connell, MD, 1,2 Khalid Ansari, MD, FRCSC, 1,2 Khalid AlQahtani, MD, FRCSC, 1,2 Jeffrey Harris, MD, FRCSC 1,2 1 Division of Otolaryngology Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. hadiseikaly@cha.ab.ca 2 Craniofacial Osseointegration and Maxillofacial Prosthetic Rehabilitation Unit (COMPRU), Edmonton, Alberta, Canada Accepted 23 June 2008 Published online 15 December 2008 in Wiley InterScience ( DOI: /hed Abstract: Background. Head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure with the preservation of function when deciding the patient s best treatment protocol. This task is especially difficult in cancer of the base of tongue. The purpose of this manuscript is to describe the beavertail modification of the radial forearm-free flap in base of tongue reconstruction. Methods. Thirty-one consecutive patients treated for base of tongue cancer with primary surgery were followed prospectively. The technique of the beavertail modification is described. Swallowing and speech function were assessed preoperatively and postoperatively. Results. All the flaps survived. Thirty (97%) patients started consuming oral diet within 1 year, and all had normal speech intelligibility. Conclusions. The beavertail modification of the radial forearm arm flap seems to provide the reconstructive elements that allow patients with large base of tongue extirpations to develop functional swallowing and speech production postoperatively. VC 2008 Wiley Periodicals, Inc. Head Neck 31: , 2009 Correspondence to: H. Seikaly VC 2008 Wiley Periodicals, Inc. Head and neck oncologists are often confronted with the difficult challenge of balancing cancer cure with the preservation of function, cosmesis, and quality of life when deciding the patient s best treatment protocol. This task is especially difficult for cancer of the base of tongue as this organ is intimately involved with the complex functions of respiration, deglutition, and speech production. 1 Treatment of advanced-stage cancers of the base of tongue generally requires a combination of surgery, radiation, and chemotherapy, but the order and extent in which these different modalities are employed continues to be controversial. The 2 widely accepted treatment regimens include (1) primary surgery and reconstruction followed by radiation and chemotherapy, and (2) organ preservation with primary concurrent chemoradiation followed by surgery for salvage or neck disease. 1 Assuming that both these regimens offer acceptable cancer control rates, the final treatment recommendation would have to depend on the protocol s functional outcomes. Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February

2 The functional outcome of primary surgical resection of the base of tongue without formal reconstruction have been unfavorable and tended to restrict the patient to a difficult life of unintelligible speech and enteral feeds. 2,3 The widespread use of free flap reconstruction has somewhat improved the patients postoperative quality of life, but reports of functional outcomes continue to be sporadic and show variable results Over the past decade, many centers have resorted to organ preservation protocols in the treatment of base of tongue cancer. The concept of functional conservation following organ preservation is quite intriguing and intuitive, but unfortunately, to date, reports of functional outcomes of these protocols have been disappointing The literature seems to offer little consensus as to which treatment regimen affords the best functional speech and swallowing. 11 Our program at University of Alberta, therefore, continues to offer both treatment options to patients with advanced base of tongue cancer. We have also developed a method of reconstruction that restores the bulk and mobility of this organ in an attempt to preserve its complex functions of respiration, deglutition, and speech production. The purpose of this manuscript is to describe this new method of base of tongue reconstruction and to report on the patients functional outcomes. PATIENTS AND METHODS Patients. Thirty-one consecutive patients treated for base of tongue cancer with primary surgery between 2001 and 2004 were enrolled with intent to follow protocol at our multidisciplinary head and neck reconstruction clinic. All patients were followed prospectively. All underwent reconstruction with the beavertail modification of the radial forearm-free flap and received a standard protocol of post-operative radiation therapy. Toward the end of the series, some patients also had concurrent adjuvant chemotherapy. All patients had extensive speech and swallowing therapy before discharge from the hospital and were given instruction in oral motor exercises to be carried out at home. Surgical Technique Resection. All patients had tumors centered in the base of tongue, but involvement of the soft palate and the lateral pharyngeal wall were common. All resections were confined to the oropharynx and did not include the oral tongue or other structures FIGURE 1. Left forearm. A large skin paddle (approximately ) centered over the radial artery and cephalic vein is outlined (BOT). The extent of the fat and fascia that is included in the flap termed the beavertail is marked out on the proximal forearm (BT). An external skin monitor is also fashioned proximally and medially if flap visualization transorally is going to be difficult postoperatively (M). in the oral cavity. Access to the oropharynx for resection and reconstruction was gained through a lip splitting incision and parasymphyseal mandibulotomy. 1 All patients had at least 1 intact hypoglossal nerve, lingual nerve, lingual artery, and lingual vein at the completion of resection. Reconstruction. All reconstructions were performed with the beavertail modification of the radial forearm-free flap site in an attempt to maintain the bulk and mobility of the neo-base of tongue. Elevation of the Radial Forearm Free Flap with Beavertail Modification. The flap elevation is performed as a 2- team approach under tourniquet control. The forearm is prepped circumlentally and a large skin paddle (approximately ) centered over the radial artery and cephalic vein is out- 214 Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February 2009

3 FIGURE 2. Left forearm. The skin paddle is elevated in the usual manner (BOT). The proximal skin is elevated in the subdermal plane (BT). The proximal fascia is then elevated with the skin paddle preserving the septum and septocutaneous perforators to the monitor if present. The flap is left pedicled on the radial artery and antecubital veins (M). lined. The extent of the fat and fascia that is included in the flap termed the beavertail is marked out on the proximal forearm. An external skin monitor is also fashioned proximally and medially if flap visualization transorally is going to be difficult postoperatively (Figure 1). The skin paddle is elevated in the usual manner. The proximal skin is then incised from the skin paddle to the antecubital fossa around the skin monitor, if present. The proximal skin is elevated in the subdermal plane preserving the underlying fat and fascia of the forearm (Figure 2). The fascia is then incised down to the forearm muscles medially and laterally and elevated off the deep muscles. The septum and septocutaneous perforators to the monitor are preserved. The elevation of the forearm flap is then completed and the flap is left pedicled on the radial artery and antecubital veins. We prefer to keep the deep and superficial drainage of the forearm flap continuous, whenever a connecting vein is present, and tend to use the antecubital vein as the only draining vessel. The flap is neurotized through FIGURE 3. Left forearm. The beavertail (BT) is dissected away from the cephalic vein and the radial pedicle on the deep surface of the flap leaving it attached to the proximal edge of the skin paddle (BOT). the lateral antibrachial cutaneous nerve if needed. The beavertail is dissected away from the cephalic vein and the radial pedicle on the deep surface of the flap leaving it attached to the proximal FIGURE 4. Left forearm. When a skin monitor is needed, the beavertail (BT) is bisected and the monitor portion of the flap remains attached to the radial pedicle through the septum and supplied by the septocutaneous perforators (M). Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February

4 FIGURE 5. The beavertail (BT) is rolled on itself. FIGURE 7. The skin is redraped over sutured to the mucosa of the defect. the beavertail and edge of the skin paddle (Figure 3). When a skin monitor is needed, the beavertail is bisected and the monitor portion of the flap remains attached to the radial pedicle through the septum and supplied by the septocutaneous perforators. The remaining beavertail is left attached to the proximal edge of the skin paddle (Figure 4). Flap Insetting. This method of flap elevation allows the beavertail portion of the flap to have freedom in 3D from the skin flap portion and vascular pedicle. The beavertail is rolled on itself and used to bulk up the base of tongue (Figures 5 and 6). The skin is redraped over the beavertail and sutured to the mucosa of the defect Figure 7. Donor Site Closure. The proximal skin is closed primarily and the skin paddle defect is covered by a split thickness skin graft. Other Surgical Maneuvers. Laryngeal suspension is performed for base of tongue resections exceeding 50% and when the suprahyoid muscles are resected bilaterally. Data Collection. All the patients were enrolled and registered into the head and neck reconstruction data base with intent to follow. Tumor- and patient-related data were collected prospectively and processed by a dedicated research assistant. Functional Assessment. Informed consent was obtained prior to functional assessment from each patient. Two speech and language pathologists collected the data using a standard protocol. All the following functional data were collected at 3 points in time: preoperatively, 1 month postoperatively before the initiation of radiation therapy, and between 6 and 9 months postoperatively after completion of radiation therapy. 1. Swallowing function was assessed via modified barium swallows, diet survey, weight, and the presence of a gastrostomy tube. 2. Speech intelligibility was assessed via Computerized Assessment of Intelligibility of Dysarthric Speech (CAIDS) (Pro-Ed, Austin, Texas). Table 1. Patient demographics. Category Subcategory N 5 31 FIGURE 6. The beavertail (BT) is used to bulk up the base of tongue. Age Average 54.6 Range Sex Male 22 (71%) Female 9 (29%) 216 Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February 2009

5 Table 2. Base of tongue defect size. Defect size (%) No. (%), N (29) 75 6 (19) (52) Table 4. G-tube placement and usage. Timing No. in place Used for primary nutritional support 1 mo postoperative 5 (16%) 5 (16%) 1 year postoperative 3 (10%) 1 (3%) Endoscopic Assessment. All the patients were followed regularly every 2 to 3 months and flexible endoscopic examination of the base of tongue reconstruction was performed. RESULTS The patient demographics are seen in Table 1. Twenty-eight (90%) patients had squamous cell carcinoma, and 3 (10%) were diagnosed with adenoid cystic carcinoma. The base of tongue defect sizes after resection are shown in Table 2. None of the patients in this series had 50% or greater soft palate resections. Twelve of the beavertail modifications had a skin monitor included in the flap design. Thirty (97%) patients had stage 3 or 4 disease and underwent postoperative radiation (27 standard, 3 intensity modulated). The beavertail showed excellent blood flow even to the most proximal portion at the end of elevation. All the flaps and their components survived. There was no statistically significant difference in the speech discrimination scores at any assessment time Table 3. A total of 30 (97%) patients were consuming normal oral diet within 1 year. The rate of gastrostomy tube placement and dependency at 1 month and 1 year are seen in Table 4. All the reconstructions maintained their volume within 1 year, postoperatively, on flexible endoscopic examination (Figures 8 and 9). tongue extirpations to develop functional swallowing and speech production postoperatively. A total of 30 (97%) patients maintained nutrition through oral intake within 1 year postoperatively, and there was no significant difference in sentence intelligibility across any of the evaluation times. This is further supported by our previous publications detailing similar outcomes and more detailed functional analyses. 4,19,20 The beavertail modification is simple to preform and does not extend the operative time significantly, especially if a 2-team approach is utilized, and provides reliable well-vascularized bulk (even though the beavertail it is supplied by random blood flow) that maintain its volume over time. Many other modifications of fasciocutaneous flaps have been described in an attempt to restore the bulk of the tongue. 9,22,23 The advantage of the beavertail modification is that the bulk has near 3-dimensional freedom from the skin flap and vascular pedicle which allows (1) precise volume tailoring of the beavertail as excessive tissue at the level of the base of tongue may result in airway DISCUSSION The beavertail modification of the radial forearmfree flap seems to provide the reconstructive elements that allow patients with large base of Table 3. Speech discrimination (sentence). Timing Discrimination (%) p value Preoperative 99 NS Postoperative 90 Postradiation 94 FIGURE 8. Endoscopic view of a reconstructed 100% base of tongue (BOT) defect at 1 year postoperatively. The reconstruction maintained its bulk. Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February

6 CONCLUSIONS The beavertail modification of the radial forearm free flap seems to provide the reconstructive elements that allow patients with large base of tongue extirpations to develop functional swallowing and speech production postoperatively. FIGURE 9. Endoscopic view of a reconstructed 75% base of tongue (BOT) defect at 1 year postoperatively. The reconstruction maintained its bulk. SP, soft palate. obstruction whereas inadequate bulk restoration may lead to poor function, and (2) exact insetting of the skin paddle to restore proper anatomic relations and maintain mobility of the remanning tongue especially if the resection encompasses multiple oropharyngeal sites. The beavertail modification allows for the reconstitution of the bulk and maintenance the mobility of the remaining tongue. The actual biomechanics of how this reconstruction restores function, postoperatively, requires a moredetailed analysis, but in the case of swallowing we believe this maneuver maintains the base of tongue and posterior pharyngeal wall apposition and permits other structures such as the pharyngeal, oral, and suprahyoid musculature to contract and generate the necessary force to propel the food bolus through the oropharynx. 20 The use of this reconstruction for salvage in organ preservation protocols is possible but the above-functional results may not be attainable as these patients swallowing is significantly compromised preoperatively as a result of their chemoradiation treatments. 14,15,17 The acknowledged weaknesses of this study include; (1) a small sample size, which may have resulted in limited statistical power, and (2) the manner in which patients resections were stratified. Although an attempt was made to group the patients based on extent of the resection, information related to the volume of resection was not available. REFERENCES 1. Seikaly H, Rassekh CH. Oropharyngeal cancer. In: Bailey B, editor. Head and neck surgery otolaryngology, 3rd ed. Philadelphia: Lippincott; Hufnagle J, Pullon P, Hufnagle K. Speech considerations in oral surgery. II. Speech characteristics of patients following surgery for oral malignancies. Oral Surg Oral Med Oral Pathol 1978;46: Hufnagle J, Pullon P, Hufnagle K. Speech considerations in oral surgery. I. Speech physiology. Oral Surg Oral Med Oral Pathol 1978;46: Seikaly H, Rieger J, Wolfaardt J, Moysa G, Harris J, Jha N. Functional outcomes after primary oropharyngeal cancer resection and reconstruction with the radial forearm free flap. Laryngoscope 2003;113: Skoner JM, Andersen PE, Cohen JI, Holland JJ, Hansen E, Wax MK. Swallowing function and tracheotomy dependence after combined-modality treatment including free tissue transfer for advanced-stage oropharyngeal cancer. Laryngoscope 2003;113: Winter SC, Cassell O, Corbridge RJ, Goodacre T, Cox GJ. Quality of life following resection, free flap reconstruction and postoperative external beam radiotherapy for squamous cell carcinoma of the base of tongue. Clin Otolaryngol Allied Sci 2004;29: Perlmutter MA, Johnson JT, Snyderman CH, Cano ER, Myers EN. Functional outcomes after treatment of squamous cell carcinoma of the base of the tongue. Arch Otolaryngol Head Neck Surg 2002;128: McConnel FM, Pauloski BR, Logemann JA, et al. Functional results of primary closure vs flaps in oropharyngeal reconstruction: a prospective study of speech and swallowing. Arch Otolaryngol Head Neck Surg 1998;124: Haughey BH, Taylor SM, Fuller D. Fasciocutaneous flap reconstruction of the tongue and floor of mouth: outcomes and techniques. Arch Otolaryngol Head Neck Surg 2002;128: Friedlander P, Caruana S, Singh B, et al. Functional status after primary surgical therapy for squamous cell carcinoma of the base of the tongue. Head Neck 2002;24: Rieger JM, Zalmanowitz JG, Wolfaardt JF. Functional outcomes after organ preservation treatment in head and neck cancer: a critical review of the literature. Int J Oral Maxillofac Surg 2006;35: Nguyen NP, Moltz CC, Frank C, et al. Dysphagia following chemoradiation for locally advanced head and neck cancer. Ann Oncol 2004;15: Nguyen NP, Moltz CC, Frank C, et al. Dysphagia severity following chemoradiation and postoperative radiation for head and neck cancer. Eur J Radiol 2006;59: Nguyen NP, Frank C, Moltz CC, et al. Aspiration rate following chemoradiation for head and neck cancer: an underreported occurrence. Radiother Oncol 2006;80: Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February 2009

7 15. Eisbruch A, Lyden T, Bradford CR, et al. Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys 2002;53: Graner DE, Foote RL, Kasperbauer JL, et al. Swallow function in patients before and after intra-arterial chemoradiation. Laryngoscope 2003;113: Kotz T, Costello R, Li Y, Posner MR. Swallowing dysfunction after chemoradiation for advanced squamous cell carcinoma of the head and neck. Head Neck 2004;26: Shiley SG, Hargunani CA, Skoner JM, Holland JM, Wax MK. Swallowing function after chemoradiation for advanced stage oropharyngeal cancer. Otolaryngol Head Neck Surg 2006;134: Rieger JM, Zalmanowitz JG, Li SY, et al. Functional outcomes after surgical reconstruction of the base of tongue using the radial forearm free flap in patients with oropharyngeal carcinoma. Head Neck 2007;29: O Connell DRJ, Hart RD, Harris JR, Seikaly H. Post-operative tongue mobility and swallowing function in the surgical treatment of tongue base cancers a prospective functional outcomes study. Arch Otolaryngol Head Neck Surg 2006;8: Urken ML, Moscoso JF, Lawson W, Biller HF. A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy. Arch Otolaryngol Head Neck Surg 1994;120: Salibian AH, Allison GR, Krugman ME, et al. Reconstruction of the base of the tongue with the microvascular ulnar forearm flap: a functional assessment. Plast Reconstr Surg 1995;96: ; discussion Radial Forearm Free Flap in Base of Tongue Reconstruction HEAD & NECK DOI /hed February