Functional reconstruction of near total glossectomy defects using composite gastro omental-dynamic gracilis flaps

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Summary

The tongue is the most commonly involved structure in cancer of the oral cavity. For locally advanced tumours, adequate resection necessitates near total or total glossectomy. Such patients pose a unique surgical challenge because of the potential for severe speech and swallowing disruption and life-threatening aspiration. These patients also undergo radiotherapy, leading to xerostomia with associated poor quality of life.

Present day techniques use dynamic muscles or musculocutaneous flaps for reconstruction of such defects which, although providing adequate glossopalatal contact and tongue movements, are still far from achieving normal tongue appearance and have no intrinsic secretory capability. We have tried to circumvent this problem by using two different free flaps simultaneously, the gracilis muscle to work as functional motor unit for providing tongue movements and elevation together with free stomach, turned inside-out, as an added source of secretion for dry mouth and attached omentum for providing adequate bulk.

This technique has been used in two patients over the last 18 months with satisfactory functional and aesthetic results.

Section snippets

Patients and methods

This technique has been used in two patients in the last 18 months; the first patient was a 63-year-old female and the second, a 35-year-old male. Both patients underwent near total glossectomy for locally advanced squamous cell carcinoma of the tongue.

The first patient achieved good speech and swallowing but died 8 months later because of metastatic disease. The second patient is presently disease free and doing well clinically, 9 months after the procedure. Both patients underwent functional

Surgical technique

The procedure started with a bilateral neck dissection (Level I–IV).

Diagastric and mylohyoid muscles were divided near the mandible and near total glossectomy was performed by pull through into the neck, including all alveolar mucosa on the lingual side. A part of uninvolved base of the tongue was left behind. The right hypoglossal nerve was tagged with 6/0 prolene suture.

The gracilis muscle was tagged with sutures at 3 cm distance to judge the correct tension at the time of muscle fixation and

Tongue movements

On nine months follow up the patient has achieved good tongue movements with capability to touch the hard palate by voluntarily elevating the neotongue.

The patient's EMG recordings show innervation of the gracilis muscle with active generation of motor unit potentials when the patient tries to elevate the tongue (Figure 2 shows the baseline and Figure 3 shows the EMG on contraction). The appearance of the reconstructed tongue at the end of 6 months is very satisfactory (Figure 4).

Swallowing

The patient

Discussion

The priorities to be considered while reconstructing total or near total glossectomy patients are airway protection, swallowing and articulation. Previously, a multitude of techniques has been described in the literature to address this challenging problem. Initial attempts started from pedicled flaps that progressed to neurotised flaps using pectoralis major muscle.7 The drawbacks were constant downward pull of gravity on the tongue and the tethering effect of the flap.

The advances in

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