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Reconstruction Following Resection of Tongue Base Cancer Using Set-back Tongue Flap
Reconstruction with Set-back Tongue Flap for Tongue Cancer Asian J Oral Maxillofac Surg 2004;16:218-223. CLINICAL OBSERVATIONS
Reconstruction Following Resection of Tongue Base Cancer Using Set-back Tongue Flap Tong Tong Lu, Wen Feng Zhang, Yi Fang Zhao Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan, China
Abstract Objective: To report the use of the set-back tongue flap for reconstruction following resection of tongue base cancer. Patients and Methods: Resection of tongue base cancer was performed via a transoral approach in 6 patients and via a transhyoid approach in 1 patient. Set-back tongue flaps were used to repair the defects created by resection of the tumour. The functional rehabilitation was evaluated at follow-up examinations. Results: One patient had two-thirds necrosis of the flap, while 6 patients had complete survival of the flaps. The flap maintained its bulk with little atrophy. Postoperative clinical examination showed that the tongue mobility, swallowing, and speech were good except for 1 patient who had tongue base cancer resection with partial supraglottic laryngectomy. Conclusion: Set-back tongue flap is a clinically viable method of reconstruction for selected patients following resection of tongue base cancer. Key words: Reconstructive surgical procedures, Surgical flaps, Tongue neoplasms
Introduction Carcinomas of the base of the tongue are frequently advanced at the time of presentation because of the relatively silent nature of the tumour and the aggressive tendency. Although considerable controversy exists in the management of cancer of the base of the tongue, surgical therapy plays an important role in the treatment of patients with tongue base carcinoma. Since resection of the tumour may cause profound postoperative swallowing and speech deficits, reconstruction has been a subject of interest for head and neck surgeons. In 1980, Schechter et al first proposed the use of the set-back anterior tongue flap to close the tongue base defect created by resection of the tumour.1 Although various pedicled myocutaneous flaps or microvascular free flaps have been used for repair of the defect of the tongue base, the set-back tongue flap is a valuable method of Correspondence: Yi Fang Zhao, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, 237 Luo Yu Road, Wuhan, China 430079. Tel: (86 027) 8764 7434; Fax: (86 027) 8787 3260; E-mail: [email protected]
218
reconstruction for selected patients. This article reports the use of set-back tongue flaps for reconstruction following resection of tongue base carcinoma.
Patients and Methods Seven patients with tongue base carcinoma underwent tumour resection and reconstruction with set-back tongue flaps at the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Wuhan University, Wuhan, China, from 1997 to 2003. There were 4 men and 3 women aged 34 to 68 years at presentation. Five patients had stage III or IV disease at presentation according to the International Union Against Cancer staging system.2 Clinically positive cervical lymph nodes were present at the time of presentation in 4 patients. No patients had evidence of distant metastases. Six patients had primary lesions involving 1 side of the tongue base and 1 had a lesion involving the tongue base bilaterally. Neck dissection was performed at the time of surgical excision of the primary lesion. Ipsilateral Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Lu, Zhang, Zhao
modified radical or radical neck dissection was performed in 6 patients. Another patient underwent ipsilateral radical neck dissection and contralateral supraomohyoid neck dissection as the tumour crossed the midline. Resection of the primary tumour in the base of the tongue was accomplished by the midline approach for 4 patients, providing adequate operative exposure to the tongue base tumour. In this procedure, the lip and mandible were split in the midline and a sagittal glossotomy was performed to the anterior margin of resection of the tongue base (Figure 1). A lateral approach was performed to expose and resect the carcinoma in 2 patients, as the tumour involved the tongue base and the posterior floor of the mouth. After a midline incision of the lower lip was made and a lip-buccal flap was raised, the mandible was divided in the region of the mandibular angle, and the lateral pharyngeal wall was incised to excise the lesion. The ipsilateral hypoglossal nerve was preserved in all patients. One patient underwent resection of the primary tumour by a transhyoid approach and partial supraglottic laryngectomy as the vallecula was invaded.
Figure 1. The lip and mandible are split in the midline and a sagittal glossotomy is performed to the anterior margin of the resection of the tongue base.
tongue was sutured on itself transorally. The mandible was restored with miniplates. The lower lip and neck was closed in layers and a suction catheter was placed in the wound. Tracheotomy was performed in 6 patients and tracheostomy was made for 1 patient who underwent partial supraglottic laryngectomy.
Results If the exposure of the tumour was via a lateral approach, the tongue was incised by a sagittal incision and the ipsilateral anterior two-thirds of the tongue became a flap based on the lingual artery (Figure 2). The flap was then set back into the defect of the tongue base and sutured posteriorly to the epiglottis, to the contralateral tongue base, and medially to the body in layers (Figure 3). The contralateral anterior
Table 1 shows the clinicopathological findings of 7 patients with tongue base carcinoma. In 6 of the 7 patients, the flaps survived completely and underwent little atrophy. Necrosis of two-thirds of the tongue was observed in 1 patient. The muscles of the oral floor were involved and the ipsilateral lingual artery was sacrificed to ensure a negative surgical margin. The necrotic tissue was removed 1 week
Figure 2. After the resection of the tongue base carcinoma, the ipsilateral anterior two-thirds of the tongue becomes a flap based on the lingual artery.
Figure 3. The flap is set back into the defect of the tongue base and posteriorly sutured to the epiglottis, to the contralateral tongue base, and medially to the body in layers.
Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
219
Reconstruction with Set-back Tongue Flap for Tongue Cancer
Patient number Age (years) Sex Diagnosis
Tumour stage Surgical approach
Defect site
Outcomes
1
50
M
Squamous cell carcinoma
T3
Midline approach
Right tongue base Flap survival No recurrence after 1 year
2
67
F
Mucoepidermoid T3 carcinoma
Midline approach
Left tongue base
3
68
F
Adenoid cystic carcinoma
T4
Lateral approach
Right tongue base Two-thirds necrosis No recurrence after 3 years
4
44
M
Adenosquamous carcinoma
T4
Lateral approach
Right tongue base Flap survival No recurrence after 5 years
5
65
F
Squamous cell carcinoma
T2
Midline approach
Left tongue base
Flap survival No recurrence after 5 years
6
34
M
Adenoid cystic carcinoma
T3
Midline approach
Left tongue base
Flap survival Died of lung metastasis in fourth postoperative year
7
56
M
Squamous cell carcinoma
T2
Suprahyoid approach Bilateral tongue base
Flap survival No recurrence after 3 years
Flap survival No recurrence after 4 years
Table 1. Clinicopathological findings of 7 patients with tongue base carcinoma.
postoperatively and the wound healed without additional surgery. Pathologically positive cervical lymph nodes were demonstrated in 3 patients. The feeding tube was removed in 6 patients 7 to 10 days postoperatively and they were able to take liquid or soft food 1 to 3 weeks after operation. Although an objective assessment of articulation was not performed, most of the patients developed understandable speech. Overall, tongue mobility, swallowing, and speech were good except for the patient who had tongue base cancer resection with partial supraglottic laryngectomy.
Case Report
The follow-up period ranged from 1 to 6 years. Only 1 patient with adenoid cystic carcinoma died of lung metastasis in the fourth year postoperatively. The other patients are still alive without tumour (Table 1).
A 50-year-old man presented with a 5-month history of a rapidly enlarging and painful swelling in the right base of the tongue. Examination revealed a hard, well-circumscribed, ulcerated swelling approximately 3.0 x 2.5 cm in size in the right base of the tongue. The tongue was freely mobile. An ipsilateral lymph node 1.0 cm in diameter was palpable in the neck. A biopsy specimen showed a moderately differentiated squamous cell carcinoma. The lesion was resected through a midline approach after performing a modified radical neck dissection (Figure 4). The surgical defect involved 75% of the ipsilateral tongue base (Figure 5). The anterior two-thirds of the tongue was formed into a flap to set back to the defect at the tongue base
Figure 4. The tongue was split by midline sagittal incision and the primary tumour in the right base of the tongue (arrows) was exposed.
Figure 5. The tongue base defect following resection of the tumour involved approximately 75% of the ipsilateral base of the tongue and the ipsilateral anterior two-thirds of the tongue became a flap.
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Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Lu, Zhang, Zhao
Figure 6. The ipsilateral anterior two-thirds of the tongue was set back to fill the tongue base defect.
Figure 8. The healed set-back tongue flap 1 year after operation.
of a set-back tongue flap to close the defect created by resection of tongue base tumour.1 After that, Bergman reported its use for carcinoma of the base of the tongue following supraglottic laryngectomy.5 Although the set-back tongue flap is not a well-known method of reconstruction of tongue base defects, it is a valuable tool for selected patients and can be developed quickly during resection of the tumour, enabling a relatively straightforward and safe procedure.
Figure 7. The set-back tongue flap was sutured to residual healthy tissue and the contralateral tongue base and body in layers.
(Figures 6 and 7). The patient was fed via a tube postoperatively. The wound healed and he was discharged on the tenth postoperative day. By the third postoperative week, the patient was able to consume a liquid diet. The patient developed understandable speech. The flap underwent little atrophy and the tongue mobility was normal when he was followed up 1 year after operation (Figure 8).
Discussion Resection of cancer of the tongue base inevitably produces swelling and speech problems. Many pedicled and free flaps have been used for reconstruction of the posterior tongue.3,4 When the tongue is reconstructed with a denervated skin flap or a myocutaneous flap, the movement of the flap is dependent on the remaining functional tongue. In 1980, Schechter et al proposed the use Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
The blood supply to the tongue comes from the bilateral lingual arteries. The lingual artery is the second branch arising from the external carotid artery. Under the hyoglossus muscle, the lingual artery divides to provide dorsal lingual branches to the base of the tongue and, at the anterior edge of the muscle, divides into 2 terminal branches — the sublingual artery and the deep lingual artery (ranine).6 The deep lingual artery supplies the mucosa and muscles of the anterior two-thirds of tongue. Resection of tongue base carcinoma usually results in sacrifice of the dorsal branch. However, the anterior two-thirds of the tongue will only have a blood supply from the deep lingual artery if the origin of the lingual artery is preserved. When the tongue is split in the midline and the tumour of the tongue base is resected, the anterior two-thirds of the tongue becomes a pedicled flap based on the lingual artery and hypoglossal nerve and may be set back to fill the tongue base defect. It is important that innervation of the lingual musculature prevents postoperative atrophy of the flap to ensure that a consistent volume of the 221
Reconstruction with Set-back Tongue Flap for Tongue Cancer
set-back tongue flap maintains anatomical symmetry and physical function. Chicarilli used a sliding posterior tongue flap based on the dorsal branch(es) of the lingual artery to repair the defect following resection of the T1 or T2 carcinoma of the midthird of the tongue.7 The set-back tongue flap is suitable for reconstruction of the unilateral tongue base defect created by resection of a carcinoma with a 3-cm diameter and not involving the lingual artery and hypoglossal nerve.8 The use of this flap is contraindicated when the lesion exceeds circumvallate papillae, for resection of tumour precludes the preservation of sufficient tissue to form the flap. The set-back tongue flap may also be used for patients with recurrent carcinoma after radiotherapy, as long as the radiation dose is within 70 cGy and the ipsilateral external carotid artery is not impaired. Schechter et al once reconstructed a tongue base defect with a set-back tongue flap and a lateral pharyngeal wall defect with another flap in a patient whose lesion originated at the tonsil and extended to the base of tongue and the lateral pharyngeal wall.1 In such a condition, the set-back tongue flap may be regarded as a ‘bridge’ to connect healthy tissue with the other flap. The set-back tongue flap is generally contraindicated when the lingual artery cannot be preserved. Among the 7 patients in this series, there were 2 patients in whom the set-back tongue flaps were used to repair the tongue base defect when the lingual artery was sacrificed. Necrosis of the flap occurred in 1 patient in whom the defect involved the right base of the tongue and the floor of the mouth. In the other patient, the flap was pale for the first 20 hours after operation but gradually returned to normal and survived despite the sacrifice of the bilateral lingual arteries. Anatomical research has shown that the blood supply to the body of the tongue is associated with the blood supply to the floor of the mouth, in which the submental artery and external maxillary artery play an important role.6,9,10 Accordingly, we considered that the body of the tongue will obtain a blood supply indirectly from the submental or external maxillary artery by way of the floor of the mouth following ligation of the lingual artery. The 222
tissue of the floor of the mouth is essential for the blood supply to the tongue. Therefore, a set-back tongue flap should not be considered for repair of a tongue base defect when the lingual artery cannot be preserved and a defect exists in the ipsilateral floor of mouth. It is interesting that the set-back tongue flap survived after the bilateral lingual arteries were sacrificed in 1 patient. This unusual case showed that the transhyoid approach in this patient avoided surgical trauma to the mandible, mucosa of the floor of the mouth, and the body of the tongue, and that the anterior tongue might have received a blood supply via the floor of the mouth following the loss of a blood supply from the lingual arteries. Besides this anatomical factor, some pathological factors that may influence the blood supply to the tongue should also be considered when the set-back tongue flap is designed and used to repair a tongue base defect. Ischaemic necrosis of the tongue is rare because of the rich vascularity, but the most frequent cause of ischaemic necrosis appears to be temporal arteritis.11 Necrosis has also been described after bilateral radical neck dissection and unilateral ligation of the external carotid artery after radiotherapy and chemotherapy,12 transient ischaemic attack accompanied by occlusion of the unilateral external carotid artery,13 and vascular calcification associated with long-standing chronic renal insufficiency.14 Although there are few reports of such conditions, these possibilities should be considered by surgeons. The set-back tongue flap is a clinically valuable method for reconstruction following resection of tongue base cancer for selected patients. However, this technique is contraindicated when the lingual artery cannot be preserved and a defect exists in the ipsilateral floor of the mouth. Pathological factors that may result in necrosis of the tongue should also be considered preoperatively.
References 1. Schechter GL, Sly DE, Roper AL 2nd, Jackson RT, Bumatay J. Set-back tongue flap for carcinoma of the tongue base. Arch Otolaryngol 1980;106:668-671. 2. Sobin LH, Witterkind CH. UICC (1997) TNM classification of malignant tumors. 5th ed. New Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Lu, Zhang, Zhao
York: Wiley-Liss; 1997. 3. Evans PH, Das Gupta AR. The use of the pectoralis major myocutaneous flap for one-stage reconstruction of the base of the tongue. J Laryngol Otol 1981;95:809-816. 4. Salibian AH, Allison GR, Krugman ME, Strelzow VV, Brugman JJ, Rappaport I, McMicken BL, Etchepare TL. Reconstruction of the base of the tongue with the microvascular ulnar forearm flap: a functional assessment. Plast Reconstr Surg 1995;96:1081-1089. 5. Bergman JA. Use of set-back tongue flap for carcinoma of the base of tongue following supraglottic laryngectomy. Laryngoscope 1983;93: 516-517. 6. Hollinshead WH. Anatomy for surgeons. Vol 1. The head and neck. 3rd ed. Philadelphia: Harper & Row Publishers; 1982. 7. Chicarilli ZN. Sliding posterior tongue flap. Plast Reconstr Surg 1987;79:697-700. 8. Wu GH, Li QD, Min HQ, Zeng ZY, Chang ZH, Chang FJ, Xie RH, Wang FG, Lin GW. Set-back tongue flap with a neurovascular pedicle for repair of tongue base carcinoma. Chin
Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Arch Otolaryngol Head Neck Surg 1998;5: 231-234. 9. Bavitz JB, Harn SD, Homze EJ. Arterial supply to the floor of the mouth and lingual gingival. Oral Surg Oral Med Oral Pathol 1994;77:232-235. 10. Hofschneider U, Tepper G, Gahleitner A, Ulm C. Assessment of the blood supply to the mental region for reduction of bleeding complication during implant surgery in the interforaminal region. Int J Oral Maxillofac Implants 1999; 14:379-383. 11. Marcos O, Cebrecos AI, Prieto A, Sancho de Salas M. Tongue necrosis in a patient with temporal arteries. J Oral Maxillofac Surg 1998;56: 1203-1206. 12. Gault DT. Tongue necrosis after radical neck dissection. Head Neck Surg 1988;10:344-345. 13. Orita Y, Ogawara T, Yorizane S, Nannba Y, Akagi H, Nishizaki K. Necrosis of the tongue after transient ischemic attack. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:316-318. 14. Bedoya RM, Gutierrez JL, Mayorga F. Calciphylaxis causing localized tongue necrosis: a case report. J Oral Maxillofac Surg 1997;55:193-196.
223
Reconstruction Following Resection of Tongue Base Cancer Using Set-back Tongue Flap Tong Tong Lu, Wen Feng Zhang, Yi Fang Zhao Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, Wuhan, China
Abstract Objective: To report the use of the set-back tongue flap for reconstruction following resection of tongue base cancer. Patients and Methods: Resection of tongue base cancer was performed via a transoral approach in 6 patients and via a transhyoid approach in 1 patient. Set-back tongue flaps were used to repair the defects created by resection of the tumour. The functional rehabilitation was evaluated at follow-up examinations. Results: One patient had two-thirds necrosis of the flap, while 6 patients had complete survival of the flaps. The flap maintained its bulk with little atrophy. Postoperative clinical examination showed that the tongue mobility, swallowing, and speech were good except for 1 patient who had tongue base cancer resection with partial supraglottic laryngectomy. Conclusion: Set-back tongue flap is a clinically viable method of reconstruction for selected patients following resection of tongue base cancer. Key words: Reconstructive surgical procedures, Surgical flaps, Tongue neoplasms
Introduction Carcinomas of the base of the tongue are frequently advanced at the time of presentation because of the relatively silent nature of the tumour and the aggressive tendency. Although considerable controversy exists in the management of cancer of the base of the tongue, surgical therapy plays an important role in the treatment of patients with tongue base carcinoma. Since resection of the tumour may cause profound postoperative swallowing and speech deficits, reconstruction has been a subject of interest for head and neck surgeons. In 1980, Schechter et al first proposed the use of the set-back anterior tongue flap to close the tongue base defect created by resection of the tumour.1 Although various pedicled myocutaneous flaps or microvascular free flaps have been used for repair of the defect of the tongue base, the set-back tongue flap is a valuable method of Correspondence: Yi Fang Zhao, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, 237 Luo Yu Road, Wuhan, China 430079. Tel: (86 027) 8764 7434; Fax: (86 027) 8787 3260; E-mail: [email protected]
218
reconstruction for selected patients. This article reports the use of set-back tongue flaps for reconstruction following resection of tongue base carcinoma.
Patients and Methods Seven patients with tongue base carcinoma underwent tumour resection and reconstruction with set-back tongue flaps at the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Wuhan University, Wuhan, China, from 1997 to 2003. There were 4 men and 3 women aged 34 to 68 years at presentation. Five patients had stage III or IV disease at presentation according to the International Union Against Cancer staging system.2 Clinically positive cervical lymph nodes were present at the time of presentation in 4 patients. No patients had evidence of distant metastases. Six patients had primary lesions involving 1 side of the tongue base and 1 had a lesion involving the tongue base bilaterally. Neck dissection was performed at the time of surgical excision of the primary lesion. Ipsilateral Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Lu, Zhang, Zhao
modified radical or radical neck dissection was performed in 6 patients. Another patient underwent ipsilateral radical neck dissection and contralateral supraomohyoid neck dissection as the tumour crossed the midline. Resection of the primary tumour in the base of the tongue was accomplished by the midline approach for 4 patients, providing adequate operative exposure to the tongue base tumour. In this procedure, the lip and mandible were split in the midline and a sagittal glossotomy was performed to the anterior margin of resection of the tongue base (Figure 1). A lateral approach was performed to expose and resect the carcinoma in 2 patients, as the tumour involved the tongue base and the posterior floor of the mouth. After a midline incision of the lower lip was made and a lip-buccal flap was raised, the mandible was divided in the region of the mandibular angle, and the lateral pharyngeal wall was incised to excise the lesion. The ipsilateral hypoglossal nerve was preserved in all patients. One patient underwent resection of the primary tumour by a transhyoid approach and partial supraglottic laryngectomy as the vallecula was invaded.
Figure 1. The lip and mandible are split in the midline and a sagittal glossotomy is performed to the anterior margin of the resection of the tongue base.
tongue was sutured on itself transorally. The mandible was restored with miniplates. The lower lip and neck was closed in layers and a suction catheter was placed in the wound. Tracheotomy was performed in 6 patients and tracheostomy was made for 1 patient who underwent partial supraglottic laryngectomy.
Results If the exposure of the tumour was via a lateral approach, the tongue was incised by a sagittal incision and the ipsilateral anterior two-thirds of the tongue became a flap based on the lingual artery (Figure 2). The flap was then set back into the defect of the tongue base and sutured posteriorly to the epiglottis, to the contralateral tongue base, and medially to the body in layers (Figure 3). The contralateral anterior
Table 1 shows the clinicopathological findings of 7 patients with tongue base carcinoma. In 6 of the 7 patients, the flaps survived completely and underwent little atrophy. Necrosis of two-thirds of the tongue was observed in 1 patient. The muscles of the oral floor were involved and the ipsilateral lingual artery was sacrificed to ensure a negative surgical margin. The necrotic tissue was removed 1 week
Figure 2. After the resection of the tongue base carcinoma, the ipsilateral anterior two-thirds of the tongue becomes a flap based on the lingual artery.
Figure 3. The flap is set back into the defect of the tongue base and posteriorly sutured to the epiglottis, to the contralateral tongue base, and medially to the body in layers.
Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
219
Reconstruction with Set-back Tongue Flap for Tongue Cancer
Patient number Age (years) Sex Diagnosis
Tumour stage Surgical approach
Defect site
Outcomes
1
50
M
Squamous cell carcinoma
T3
Midline approach
Right tongue base Flap survival No recurrence after 1 year
2
67
F
Mucoepidermoid T3 carcinoma
Midline approach
Left tongue base
3
68
F
Adenoid cystic carcinoma
T4
Lateral approach
Right tongue base Two-thirds necrosis No recurrence after 3 years
4
44
M
Adenosquamous carcinoma
T4
Lateral approach
Right tongue base Flap survival No recurrence after 5 years
5
65
F
Squamous cell carcinoma
T2
Midline approach
Left tongue base
Flap survival No recurrence after 5 years
6
34
M
Adenoid cystic carcinoma
T3
Midline approach
Left tongue base
Flap survival Died of lung metastasis in fourth postoperative year
7
56
M
Squamous cell carcinoma
T2
Suprahyoid approach Bilateral tongue base
Flap survival No recurrence after 3 years
Flap survival No recurrence after 4 years
Table 1. Clinicopathological findings of 7 patients with tongue base carcinoma.
postoperatively and the wound healed without additional surgery. Pathologically positive cervical lymph nodes were demonstrated in 3 patients. The feeding tube was removed in 6 patients 7 to 10 days postoperatively and they were able to take liquid or soft food 1 to 3 weeks after operation. Although an objective assessment of articulation was not performed, most of the patients developed understandable speech. Overall, tongue mobility, swallowing, and speech were good except for the patient who had tongue base cancer resection with partial supraglottic laryngectomy.
Case Report
The follow-up period ranged from 1 to 6 years. Only 1 patient with adenoid cystic carcinoma died of lung metastasis in the fourth year postoperatively. The other patients are still alive without tumour (Table 1).
A 50-year-old man presented with a 5-month history of a rapidly enlarging and painful swelling in the right base of the tongue. Examination revealed a hard, well-circumscribed, ulcerated swelling approximately 3.0 x 2.5 cm in size in the right base of the tongue. The tongue was freely mobile. An ipsilateral lymph node 1.0 cm in diameter was palpable in the neck. A biopsy specimen showed a moderately differentiated squamous cell carcinoma. The lesion was resected through a midline approach after performing a modified radical neck dissection (Figure 4). The surgical defect involved 75% of the ipsilateral tongue base (Figure 5). The anterior two-thirds of the tongue was formed into a flap to set back to the defect at the tongue base
Figure 4. The tongue was split by midline sagittal incision and the primary tumour in the right base of the tongue (arrows) was exposed.
Figure 5. The tongue base defect following resection of the tumour involved approximately 75% of the ipsilateral base of the tongue and the ipsilateral anterior two-thirds of the tongue became a flap.
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Lu, Zhang, Zhao
Figure 6. The ipsilateral anterior two-thirds of the tongue was set back to fill the tongue base defect.
Figure 8. The healed set-back tongue flap 1 year after operation.
of a set-back tongue flap to close the defect created by resection of tongue base tumour.1 After that, Bergman reported its use for carcinoma of the base of the tongue following supraglottic laryngectomy.5 Although the set-back tongue flap is not a well-known method of reconstruction of tongue base defects, it is a valuable tool for selected patients and can be developed quickly during resection of the tumour, enabling a relatively straightforward and safe procedure.
Figure 7. The set-back tongue flap was sutured to residual healthy tissue and the contralateral tongue base and body in layers.
(Figures 6 and 7). The patient was fed via a tube postoperatively. The wound healed and he was discharged on the tenth postoperative day. By the third postoperative week, the patient was able to consume a liquid diet. The patient developed understandable speech. The flap underwent little atrophy and the tongue mobility was normal when he was followed up 1 year after operation (Figure 8).
Discussion Resection of cancer of the tongue base inevitably produces swelling and speech problems. Many pedicled and free flaps have been used for reconstruction of the posterior tongue.3,4 When the tongue is reconstructed with a denervated skin flap or a myocutaneous flap, the movement of the flap is dependent on the remaining functional tongue. In 1980, Schechter et al proposed the use Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
The blood supply to the tongue comes from the bilateral lingual arteries. The lingual artery is the second branch arising from the external carotid artery. Under the hyoglossus muscle, the lingual artery divides to provide dorsal lingual branches to the base of the tongue and, at the anterior edge of the muscle, divides into 2 terminal branches — the sublingual artery and the deep lingual artery (ranine).6 The deep lingual artery supplies the mucosa and muscles of the anterior two-thirds of tongue. Resection of tongue base carcinoma usually results in sacrifice of the dorsal branch. However, the anterior two-thirds of the tongue will only have a blood supply from the deep lingual artery if the origin of the lingual artery is preserved. When the tongue is split in the midline and the tumour of the tongue base is resected, the anterior two-thirds of the tongue becomes a pedicled flap based on the lingual artery and hypoglossal nerve and may be set back to fill the tongue base defect. It is important that innervation of the lingual musculature prevents postoperative atrophy of the flap to ensure that a consistent volume of the 221
Reconstruction with Set-back Tongue Flap for Tongue Cancer
set-back tongue flap maintains anatomical symmetry and physical function. Chicarilli used a sliding posterior tongue flap based on the dorsal branch(es) of the lingual artery to repair the defect following resection of the T1 or T2 carcinoma of the midthird of the tongue.7 The set-back tongue flap is suitable for reconstruction of the unilateral tongue base defect created by resection of a carcinoma with a 3-cm diameter and not involving the lingual artery and hypoglossal nerve.8 The use of this flap is contraindicated when the lesion exceeds circumvallate papillae, for resection of tumour precludes the preservation of sufficient tissue to form the flap. The set-back tongue flap may also be used for patients with recurrent carcinoma after radiotherapy, as long as the radiation dose is within 70 cGy and the ipsilateral external carotid artery is not impaired. Schechter et al once reconstructed a tongue base defect with a set-back tongue flap and a lateral pharyngeal wall defect with another flap in a patient whose lesion originated at the tonsil and extended to the base of tongue and the lateral pharyngeal wall.1 In such a condition, the set-back tongue flap may be regarded as a ‘bridge’ to connect healthy tissue with the other flap. The set-back tongue flap is generally contraindicated when the lingual artery cannot be preserved. Among the 7 patients in this series, there were 2 patients in whom the set-back tongue flaps were used to repair the tongue base defect when the lingual artery was sacrificed. Necrosis of the flap occurred in 1 patient in whom the defect involved the right base of the tongue and the floor of the mouth. In the other patient, the flap was pale for the first 20 hours after operation but gradually returned to normal and survived despite the sacrifice of the bilateral lingual arteries. Anatomical research has shown that the blood supply to the body of the tongue is associated with the blood supply to the floor of the mouth, in which the submental artery and external maxillary artery play an important role.6,9,10 Accordingly, we considered that the body of the tongue will obtain a blood supply indirectly from the submental or external maxillary artery by way of the floor of the mouth following ligation of the lingual artery. The 222
tissue of the floor of the mouth is essential for the blood supply to the tongue. Therefore, a set-back tongue flap should not be considered for repair of a tongue base defect when the lingual artery cannot be preserved and a defect exists in the ipsilateral floor of mouth. It is interesting that the set-back tongue flap survived after the bilateral lingual arteries were sacrificed in 1 patient. This unusual case showed that the transhyoid approach in this patient avoided surgical trauma to the mandible, mucosa of the floor of the mouth, and the body of the tongue, and that the anterior tongue might have received a blood supply via the floor of the mouth following the loss of a blood supply from the lingual arteries. Besides this anatomical factor, some pathological factors that may influence the blood supply to the tongue should also be considered when the set-back tongue flap is designed and used to repair a tongue base defect. Ischaemic necrosis of the tongue is rare because of the rich vascularity, but the most frequent cause of ischaemic necrosis appears to be temporal arteritis.11 Necrosis has also been described after bilateral radical neck dissection and unilateral ligation of the external carotid artery after radiotherapy and chemotherapy,12 transient ischaemic attack accompanied by occlusion of the unilateral external carotid artery,13 and vascular calcification associated with long-standing chronic renal insufficiency.14 Although there are few reports of such conditions, these possibilities should be considered by surgeons. The set-back tongue flap is a clinically valuable method for reconstruction following resection of tongue base cancer for selected patients. However, this technique is contraindicated when the lingual artery cannot be preserved and a defect exists in the ipsilateral floor of the mouth. Pathological factors that may result in necrosis of the tongue should also be considered preoperatively.
References 1. Schechter GL, Sly DE, Roper AL 2nd, Jackson RT, Bumatay J. Set-back tongue flap for carcinoma of the tongue base. Arch Otolaryngol 1980;106:668-671. 2. Sobin LH, Witterkind CH. UICC (1997) TNM classification of malignant tumors. 5th ed. New Asian J Oral Maxillofac Surg Vol 16, No 4, 2004
Lu, Zhang, Zhao
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