Tongue reconstruction using VRAM flap after staged neck dissection and total glossectomy for squamous cell carcinoma

Abstract

Objectives. Tongue reconstruction uses various free flaps: radial or ulnar forearm, rectus abdominis muscle or anterolateral thigh flap among others. We present the case of a 21-years old male with squamous cell carcinoma of the anterior 2/3 of the tongue (classifcation IIa[1]) and right submandibular adenopathy. Patient underwent staged operations: radical modifed bilateral neck dissection and VRAM flap reconstruction following the subtotal glossectomy. Particulars of the case, the advantages, specifc adjunctive treatments and the medium-term outcome are shown. Material and methods. The patient presented with impaired swallowing and phonation due to tongue tumor growing for two years. Tumor biopsy confrmed squamous cell carcinoma. Feeding tube and intense metabolic reanimation brought patient to adequate BMI preoperatively. First stage: tracheostomy and bilateral modifed radical neck dissection were performed. Two days later, after mandible osteotomy, two thirds of the anterior aspect of the tongue, mouth floor and associated ganglia were excised. The resulting defect was covered using free vertical rectus abdominis muscle flap (VRAM) on deep inferior epigastric pedicle anastomosed to superior thyroid artery and internal jugular branch, respectively. The muscle bulk was placed in the middle of the defect, with the three-lobed skin paddle placed outside and the lateral wings forming the sublingual folds. Mandibular osteosynthesis was performed using screws and plate. For the abdominal wall closure the components separation was used. Radiotherapy was initiated two months after the surgery and the patient underwent the full protocol. Results. Histological exam confrmed tongue squamous cell carcinoma with safe resection margins. Flap survived entirely. Early oro-cervical salivary fstula was closed using sutures and tissue adhesive. The tracheostomy was closed and PEG tube remained in place for an additional for weeks until patient resumed complete oral diet, confrmed by X-ray exam. Speech is satisfactory both for patient and doctor. Wound dehiscence post-radiotherapy healed in 2 months with assisted secondary healing. Conclusions. VRAM flap was successfully used in tongue reconstruction after subtotal glossectomy. The bulk needed is provided by the muscle part while the sulcus is re-created by the foldable skin flap. Minor complications were solved and one year follow-up showed normal feeding, satisfactory speech and no recurrence.