Adipofascial anterolateral thigh free flap for tongue repair

Transcription

1 The British Association of Plastic Surgeons (2003) 56, CASE REPORT Adipofascial anterolateral thigh free flap for tongue repair V. Agostini*, M. Dini, A. Mori, A. Franchi, T. Agostini Department of Plastic Surgery, University of Florence, C.T.O., Largo Palagi 1, Florence 50139, Italy Received 24 June 2002; accepted 30 May 2003 KEYWORDS Tongue reconstruction; Anterolateral thigh flap; Tongue sensitivity recovery Summary With the advent of microsurgery fasciocutaneous free flaps have become a well known and accepted option for the repair of tongue defects. Many authors have tried to recover tongue function by modifying this approach. An innovative method for the repair of tongue defects using an adipofascial anterolateral thigh free flap is presented in this paper. The results are compared with those of tongue reconstructions implementing traditional fasciocutaneous free flaps performed at our institution. The histological features of the flaps were investigated postoperatively. Although this preliminary report has to be confirmed by further experience, it seems to solve many tongue-reconstruction related problems. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. The restoration of the function of the highly specialised tissues of the tongue is one of the great challenges for the plastic surgeon. Until the advent of microsurgery, patients with major tongue defects were treated with local flaps 1 and later by regional fasciocutaneous, muscular and myocutaneous flaps. 2 5 In the past 15 years, the fasciocutaneous forearm free flap has been the flap most used for tongue reconstruction. Its pliability and thinness make it ideal for use in oral cavity defects. 6 9 In some cases, the reconstruction of more than half a tongue has been attempted using the reinnervated rectus abdominis myocutaneous flap. However, no taste sensitivity can be recovered using these flaps and protective sensation recovery never reached a satisfying level. 10 In the last 10 years, the anterolateral thigh flap, first reported by Song et al., 11 has come into popular use. 12 This article puts forth a new approach to tongue reconstruction using an adipofascial anterolateral thigh flap. *Corresponding author. Tel.: þ ; fax: þ Fig. 1 The carcinoma of the right border of the tongue. S /03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi: /s (03)

2 Adipofascial anterolateral thigh free flap for tongue repair 615 Fig. 2 The flap risen from the right thigh. The white arrow shows the pedicle. Fig. 3 The flap inset in the oral cavity with its fascial surface outwards. Fig. 5 (A B) Comparative histological views with hematoxylin and eosin coloration of the tongue (A) and the flap (B). Fig. 4 Result after 45 days.

3 616 V. Agostini et al. Case report In May 2001, a 50-year-old man presented with a squamous cell carcinoma of the mobile right tongue border (Fig. 1). Clinical examination of the neck was negative. The patient underwent resection of the mobile right half part of the tongue with conservative neck dissection. A cm 2 anterolateral fasciocutaneous thigh flap supplied by an 8 cm vascular pedicle was harvested from the right leg (Fig. 2). During the procedure, the flap was converted into an adipofascial flap, the skin excised and trimmed to fit the tongue defect. Then the flap was sutured to the residual tongue in a reverse fashion with the fascial surface outward. The artery and vein were anastomosed end to end to the superior thyroid artery and the external jugular vein (Fig. 3). The thigh defect was closed directly. The 13th day after surgery, the patient had a pulmonary embolism due to left popliteal vein thrombosis and underwent thrombolitic therapy. Regarding the reconstruction, no surgical complication occurred in the postoperative period. The donor site wound healed uneventfully. The patient was discharged with a soft diet on day 30. His speech was rated intelligible. Forty-five days after surgery the clinical aspect of the reconstructed tongue was identical to the residual tongue. Its mobility was limited in tip protrusion, but it was able to transfer a bolus to the pharynx at will, and the patient did not require head-tilting to swallow (Fig. 4). The hot and cold and touch sensitivity of the neo-tongue did not differ from that of the residual tongue and even taste sensitivity was recovered. The physical aspect of the flap resembled that of a normal tongue with taste buds covering the mucosa. The result of the biopsy of a specimen of the neo-tongue compared to the biopsy of the residual tongue did not show any relevant difference. Both specimens showed a squamous epithelial lining, and a mild inflammatory infiltrate was present in the lamina propria (Fig. 5). Small stromal nerve structures were detectable in both biopsy specimens using an immunohistochemical staining for S-100 protein (Fig. 6). Discussion Since the era of microsurgery, many surgeons focus on restoring the tongue s sensitivity and mobility. 8, 10,13 16 However, taste sensation has never been tested because the flap s epithelium lacked the taste buds which cover the tongue mucosa. In some cases, a mucous membranous metaplasia of the Fig. 6 (A B) Comparative histological views of the tongue (A) and the flap (B) using an immunohistochemical staining against S-100 protein.

4 Adipofascial anterolateral thigh free flap for tongue repair 617 fasciocutaneous flap used for tongue reconstruction has been observed one year after surgery, but there was no regeneration of taste buds and the patient was unable to recognise taste on the flap. 17 The transfer of free microvascular jejunal patches was attempted to reproduce a mucous producing mucosa, but its harvest is complicated when compared with the fascial flaps. 18 The idea of using fascial flaps for oral cavity reconstruction is not new. Many authors studied the remucosalisation of the myofascial pectoralis major flap used to cover oral mucosa defects and their histological results showed that the flap was covered with a thin layer of squamous mucosa 1 month after surgery. This result was not influenced by the subsequent radiotherapy treatment. 22,23 Later, when the practice of using a fasciocutaneous radial forearm free flap for oral cavity reconstruction was well established, the idea of fascial flap prelamination was proposed, 24 but delayed tumor resection should usually be avoided. At our institution, we used to perform tongue reconstruction using the forearm free flap according to Soutar s technique. All cutaneous flaps give the tongue a patching aspect since their surface continues to be constituted by a hairy keratinized epithelium. In two cases, forearm cutaneous flaps resembled a normal tongue due to their pinkish color three months following surgery (Fig. 7). Radiotherapy was administered to both patients in the post-op period and the biopsy of the flaps showed the presence of inflammatory cells in the context of a keratinized epithelium, but no mucosa regeneration was observed. We chose the anterolateral thigh free flap for tongue repair because of the low morbidity of the donor site. When excising the skin from the flap, we found the thick and strong fascia an ideal field for allowing the lingual mucosa to spontaneously regenerate, avoiding the patching aspect of the cutaneous flaps, and obtaining better functional results. 25 Moreover, the flap can be thinned as far as it fits the tongue defect with no risk. Although the results of this case must be confirmed by further experience, this study suggests a new approach to tongue reconstruction. References Fig. 7 Normal tongue appearance of the forearm free flap used for tongue reconstruction after radiotherapy treatment. 1. McGregor IA. The temporal flap in intraoral cancer: its use in repairing the postexcisional defect. Br J Plast Surg 1963;16: Bakamjian VY, Long M, Rigg B. Experience with medically based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg 1971;24: Keyserlingk JR, de Francesco J, Breach N, Rhys-Evans P, Stafford N, Mott A. Recent experience with reconstructive surgery following major glossectomy. Arch Otolaryngol Head Neck Surg 1989;115: Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63: Baek SM, Biller HF, Krespi YP, Lawson W. The pectoralis major myocutaneous island flap for reconstruction of the head and neck. Head Neck Surg 1979;1: Soutar DS, McGregor IA. The radial forearm flap in intraoral reconstitution: the experience of 60 consecutives cases. Plast Reconstr Surg 1986;78: Soutar DS, Sheker LR, Tanner NSB, McGregor IA. The radial forearm flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36: Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense? Plast Reconstr Surg 1994;93: Urken ML, Weinberg H, Vickery C, Biller HF. The neurofasciocutaneous radial forearm flap in head and neck reconstruction: a preliminary report. Laryngoscope 1990;100: Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of innerveated and noninnervated free flaps in oral reconstruction. Plast Reconstr Surg 1999;104: Song YG, Chen GZ, Song YL. The free thigh flap: a new free

5 618 V. Agostini et al. flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37: Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Soeda S, Ohta S. Free anterolateral thigh flap for reconstruction of head and neck defects. Plast Reconstr Surg 1993;92: Matloub HS, Larson DL, Kuhn JC, Yousif NJ, Sanger JR. Lateral arm free flap in oral cavity reconstruction: a functional evaluation. Head Neck 1989;11: Urken ML, Weinberg H, Vickery C, et al. The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy mandibulectomy defects. Laryngoscope 1992;102: 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;120: Santamaria E, Wei F, Chen I, Chuang DC. Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction by using different recipient nerves. Plast Reconstr Surg 1999;103: Ikeda K, Yokoyama M, Okada K, Tomita K, Nagayama I. Oral reconstruction using the peroneal flap. Br J Plast Surg 1997; 50: Sheen R. Reconstruction of intraoral mucosal defects with revascularized jejunal segments. Microsurgery 1994;15: Moloy PJ. Reconstruction of intermediate sized mucosal defects with the pectoralis major myofascial flap. J Otolaryngol 1989;18: Phillips JG, Postlethwaite K, Peckitt N. The pectoralis major muscle flap without skin in intraoral reconstruction. Br J Oral Maxillofac Surg 1988;26: Johnson MA, Langdon JD. Is skin necessary in intraoral reconstruction with myocutaneous flaps? Br J Oral Maxillofac Surg 1990;28: Shindo ML, Costantino PD, Friedman CD, Pelzer HJ, Sisson GA, Bressler FJ. The pectoralis major myofascial flap for intraoral and pharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1992;118: Gras R, Bouvier C, Guelfucci B, Robert D, Giovanni A, Zanaret M. Applications du lambeau fascio-muscolaire de grand pectoral dans la chirurgie de l oro-bucco-pharynx et pharyngo-larynge en rattrapage. Ann Otolaryngol Chir Cervicofac 2000;117(6): Rath T, Millesi W, Millesi-Schobel G, Lang S, Glaser C, Todoroff B. Mucosal prelaminated flaps for physiological reconstruction of intraoral defects after tumor resection. Br J Plast Surg 1997;50: Martin IC, Brown AE. Free vascularized fascial flap in oral cavity reconstruction. Head Neck 1994;16:45 50.