ARTÍCULO CLÍNICO

 

Double pad radial free flap to reconstruct touque and floor of the mouth

Colgajo libre radial de doble paleta cutánea para reconstrucción de lengua y suelo de boca

 

 

M. Acosta Feria¹, P. Infante Cossío², A. García-Perla García², E. Torres Carranza¹,
R. Belmonte Caro², J.L. Gutiérrez Pérez³

1 Médico Residente.
2 Médico Adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial.
Hospitales Universitarios Virgen Del Rocío. Sevilla, España.

Dirección para correspondencia

 

 

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ABSTRACT

Introduction: The firearm injuries are not very common in our country, and the experience in its management is limited. In this review we show the experience of our Service in this wounds and review the literature to systematize the initial management of the firearm injuries in maxillofacial region.
Material and Methods: We present six patients treated in our Service in 2002. We study the demographics characteristic, aetiology, lesions patterns and treatment.
Results: Five male and a female were treated of firearm lesions during this period, with a mean age of 38 years (range 13-74). Most frequent aetiology was the aggression. Only one patient required emergency airway control with tracheotomy. No complications were noted after primary surgical treatment and only one patient needed secondary surgical intervention.
Discussion: There are controversy in definitive surgical treatment in patients with high-energy lesions in maxillofacial region, because the literature describe two forms of management. The first way is the primary reconstruction with microvascular techniques, or secondary reconstruction after desbridement, stabilization of existing bone and primary closure of soft tissue. We think that the choice of treatment must be individualized, and we choose the secondary reconstruction as early as possible after primary stabilization of wounds.

Key words: Firearm; Maxillofacial injuries; Reconstruction.

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RESUMEN

Introducción. La cirugía reconstructiva tras la exéresis de tumores malignos que afectan a la lengua y al suelo de boca, continúa siendo uno de los grandes retos de la cirugía oral y maxilofacial. La mayor recuperación del habla y de la deglución, van a ser los objetivos finales de toda la reconstrucción de la cavidad oral. Presentamos un nuevo diseño del colgajo libre radial para la cirugía reconstructiva del carcinoma lengua y suelo de boca.
Material y método. Nuestra serie consta de tres pacientes diagnosticados de carcinoma epidermoide de lengua y suelo de boca. Tras la cirugía oncológica ablativa, se reconstruyó el defecto oral con un colgajo libre radial de doble paleta cutánea con zona intermedia desepidermizada microvascularizado.
Resultados. La movilidad de la lengua de nuestros pacientes fue suficiente y adecuada, consiguiéndose una buena calidad de vida. No hubo pérdida de la comida u otros fluidos a través del tracto respiratorio.
Conclusiones. Con el colgajo radial de doble paleta cutánea microvascularizado, se consigue una buena recuperación funcional tanto en el habla como en la deglución en los pacientes, por lo que creemos que debería estandarizarse su uso en la cirugía reconstructiva oral tras la exéresis de tumores malignos de lengua y suelo de boca.

Palabras clave: Colgajo libre radial; Carcinoma de lengua; Reconstrucción de la cavidad oral.

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Introduction

Reconstructive surgery following the resection of tumors of the head and neck has seen great advances over recent years, and it has been perfected. The surgical objectives have changed, as initially these just entailed direct closure, while now these involve the more complex forms of current restorations, which permit the restoration of the anatomic structure and functions of the resected areas.¹ The principal objective of all reconstruction is to achieve maximum functional recovery for the patient, with the reconstruction of the tongue being the most important factor in this recovery. However, current reconstructive techniques have still to achieve the complex arrangement of the tongue’s muscle fibers and its extraordinary range of movements. What is known is that after a partial glossectomy, maintaining the mobility of the residual tongue is of primordial importance while restoring the mucosal surface of the mouth. The innervated free flaps have been proposed as the other form of guaranteeing a high degree of recovery with regard to swallowing, speech and protection of the airways in the reconstruction of the tongue.

Of the free flaps used in lingual reconstruction, the radial microvascularized forearm free flap popularized by Soutar², has become the flap of choice, not only for reconstruction of the tongue, but in general for soft tissues of the oral cavity and pharynx.^3-6 The radial forearm flap provides thin tissue that is superfluous, malleable and flexible, characteristics that are critical when conserving the mobility of the tongue.^3,6,7

In 1994 Urken designed a bilobed fasciocutaneous radial forearm flap that enabled separating the mobile tongue from the floor of the mouth and gums during the reconstruction. As a result the postoperative mobility of the new tongue was maximized.⁸

After consulting the literature, we present a new design for a microvascularized radial forearm flap, following a modification of those already described, by making two totally independent skin paddles by means of a de-epithelialized zone in order to recreate the natural anatomic shape of the tongue and floor of the mouth. Thus, the reconstruction of the tongue and the floor of the mouth and gums are individualized. Our flap was used in the reconstruction of the oral cavity of three patients who were diagnosed with squamous cell carcinoma of the tongue and floor of the mouth, and who all underwent oncological ablative surgery.

 

Material and method

We present three patients who were diagnosed with squamous cell carcinoma of the tongue and floor of the mouth. The areas measured more than 4 cm in diameter and there was extension to neighboring structures (T3). A partial glossectomy and exeresis of the floor of the mouth was carried out and the surgical defect was reconstructed with a radial forearm free flap with two skin paddles that were separated by an intermediate de-epithelialized area. In none of the cases were the flaps seen to fail, nor were there any other complications. The patients were operated on between 2000 and 2001. The follow-up period ranged from 12 to 18 months.

Two teams carried out the surgical intervention of each patient; the first team carried out the exeresis of the tumor and neck dissection, while the second removed the radial forearm flap for later reconstruction. Two skin paddles were designed with a longer axis that was perpendicular to the vessels in the forearm; the distal paddle was used for the reconstruction of the tongue, and the proximal paddle for the floor of the mouth. The proportion of the two paddles varied according to the defect to be reconstructed. An intermediate de-epithelialized area between both paddles with a width of 1 cm was designed as a sort of bridge, which permitted the improved anatomic fixation of both skin paddles. The flap was inserted in the receptor area. The distal area of the distal skin paddle was sutured to the tongue, while the proximal area of the proximal skin paddle was sutured to the gums, allowing the de-epithelialized area movement of both structures (Fig. 1). Microvascular anastomosis was carried out with branches of the external carotid artery and the thyro-linguo-facial trunk. The lateral antebrachial cutaneous nerve was sutured to the lingual nerve using 9-0 nylon.

 

Patient 1

Fifty-six year old patient with squamous cell carcinoma of the tongue and floor of the mouth. Two-thirds of the mobile tongue and of the floor of the mouth was removed by means of a pull-through procedure. Bilateral cervical supra-omohyoid dissection was carried out. A radial forearm free flap with two skin paddles and an intermediate de-epithelialized area was extracted from the non-dominant arm. The lingual defect was reconstructed with the distal paddle while the floor of the mouth was reconstructed with the proximal paddle, separated by a de-epithelialized area of 1 cm. The patient received postoperative radiotherapy. The result a year after completing the treatment is shown in figure 2. The functional recovery and the sensitivity of the new tongue were good. Oral food intake was re-established prior to the patient’s release. The mobility of the tongue was adequate and enough to enable speech. Sensation in the tongue was recovered three months after surgery, and the patient was satisfied with the results.

 

 

Patient 2

Male patient, 51 years old, diagnosed with squamous cell carcinoma and cervical metastatic lymph nodes. He underwent a resection of two thirds of the tongue and floor of the mouth. A bilateral cervical supra-omohyoid dissection was carried out. The surgical defect was reconstructed with a radial forearm flap with two skin paddles and an intermediate deepithelialized area (Fig. 3). The patient received postoperative radiotherapy. Eighteen months after the surgery he had good functional recovery of speech and swallowing. Sensation in the reconstructed tongue returned gradually after the surgery. After four months the patient was able to locate pain stimuli at different points of the tongue.

 

 

Patient 3

Male patient, 53 years old, experienced recurrence of squamous cell carcinoma in the anterior two-thirds of the tongue after radiotherapy. The mobile portion of the tongue was removed. Radical dissection was carried out of right side and the left supra-omohyoid side. A radial forearm free flap was harvested with two skin paddles together with an intermediate de-epithelialized area of the non-dominant arm. The proximal skin paddle (6 cm long) was used for reconstructing the tongue, while the distal area was used for restoring the floor of the mouth (Fig. 4). Twelve months after surgery, the reconstruction showed good functional and aesthetic result. The patient did not need a gastrostomy feeding tube. His articulation was enough to enable him to carry out his normal activities. Sensation in the reconstructed tongue was recovered two months after the operation. Slowly his perception of pain, temperature and pressure returned.

 

 

Results

During the follow-ups carried out after their discharge, the extent of speech recovery as well as swallowing function was evaluated in all patients, in addition to sensory recovery in the receptor area. Good recovery was observed in speech as well as in swallowing in our patients, which is the final objective in all reconstruction after exeresis of squamous cell carcinomas of the tongue and floor of the mouth. In addition, lingual mobility that was sufficient and acceptable was achieved, and a good quality of life was achieved for the patients. Aspiration into the respiratory tract of food or secretions was not observed, and gastrostomy feeding was not required for any of the patients.

 

Discussion

Carcinoma of the oral cavity is treated with surgery, radiotherapy or a combination of both depending on the size of the tumor, the location and on other factors. The reconstruction of tongue is the basic factor for the restoration of function after ablative oncological surgery for malignant tumors of the oral cavity. It is particularly important in the oral cavity that the method of reconstruction maintains speech, mastication and swallowing functions. The ideal reconstruction technique should provide: viable soft tissue with an epithelial surface that is similar to mucosa. Lastly the flap should also cover the bone surface area and be resistant to masticatory trauma.⁹

There are multiple factors that reconstructive surgery is not able to control when the rehabilitation of a patient after a glossectomy is attempted: the quantity of the residual tongue, the integrity of motor and sensory nerves, the degree of fibrosis of the residual tongue musculature after surgery and radiotherapy, and other factors relating to the patient (such as age, medical condition and motivation).⁵ Lingual function is determined by various factors: the complex activity of the different muscles that vary their shape and position, the lubrication of the mucosa and lingual surface, and sensory innervation feedback that indicates pain, temperature, touch, proprioceptive sense and taste. For improving the mobility of the reconstructed tongue, we have to take into account three surgical aspects: the introduction of a fine, pliable tissue, the use of superfluous tissue and the separation when carrying out the reconstruction of the mobile tongue and the floor of the mouth and gingiva.⁸ The traditional form of reconstruction after a glossectomy has been the reconstruction with myocutaneous free or pedicled flaps, and it is currently the radial forearm free flap that is ideal for maximum recovery of lingual mobility, although for reconstructing greater defects of soft parts of the oral cavity other flaps can be used such a the rectal free flap.⁶

In 1994 Urken and cols. designed a bilobed radial forearm flap that permitted separating the mobile tongue from the floor of the mouth and gingiva during the reconstruction. As a result postoperative mobility of the new tongue was maximized.⁸ Our new design with a double skin paddle increases the mobility of the reconstructed tongue, and as a result speech and swallowing function is improved together with the protection of the patient’s airways, as the reconstruction of the tongue, floor of the mouth and gingiva is totally individualized because of the area that has been de-epithelialized.

The radial forearm free flap has been used for the reconstruction of cranial base defects,¹⁰ in mandibular reconstruction as an osteocutaneous flap (but today it has been superseded by the microvascular fibular flap,)¹¹ and for soft palate defects,⁴ with it currently being indicated chiefly for reconstructions of the oral cavity after the resection of tumors affecting the tongue and floor of the mouth. Within lingual reconstruction, the radial forearm flap has been used for the reconstruction of the mobile tongue (with microanastamosis being carried out of the lingual arteries with the radial artery),¹² as well as the reconstruction of the base of the tongue with laryngeal preservation.¹³

Various studies have analyzed the degree of functional recovery achieved after the reconstruction of lingual defects with the radial forearm free flap, fundamentally with regard to speech and swallowing of the patient. In addition, there are studies that try to evaluate the extension and degree of spontaneous recovery of sensation after the reconstruction of the oral cavity and oropharynx with noninnervated radial forearm free flaps; these studies measure five sensory modalities: pressure, pain, temperature (cold and hot) and two point discrimination, with the use of noninnervated radial forearm flaps,^14,15 or innervated, generally between the medial or lateral antebrachial cutaneous nerves and the lingual nerve.^1,6,8

Jacobson and cols evaluated: swallowing, lingual mobility, mobility of the mandibular lip and of the soft palate, lingual control of the lips and of the mandible, mastication, oral cavity sensation, oropharyngeal sensation, speech and the postoperative appearance of structures. It was discovered that the functional outcome obtained varied according to the location of the tumor excised and, as a result, the area reconstructed.⁷ Haughey evaluated the degree of postoperative recovery with regard to speech and swallowing of the patients, and he made a comparison between glossectomies that affected just the mobile tongue and those affecting the base of the tongue.¹⁶ In our opinion, and in view of the results obtained, the radial forearm free flap with a double skin paddle improves functional recovery.

Complications in the donor site that have been described include: loss of part of the skin graft used for closing the donor site of the flap and global necrosis of the skin graft, exposure of tendons, delay in the closure of the defect, sensation changes of the forearm because of damage to the medial or lateral antebrachial cutaneous nerves, infection of the donor site, reduction of sensation of the thumb and thenar eminence, and lastly painful neurinomas by the nerve cables.^17-19 In our series, none of these complications arose.

 

Conclusion

The final objective when reconstructing the anatomic defects produced by oncological surgery of tumors of the oral cavity, is the recovery as far as possible of speech and swallowing functions, and the protection of the airways. The fact that the tongue, floor of the mouth and gingiva can be reconstructed in an individualized fashion, means that a greater degree of lingual mobility is achieved, which means that the functional recovery of the patient and postoperative quality of life is improved. In addition to this, as this flap has sensitivity, after the anastomosis of the nerves, the reconstructed area will recover sensation. Although our series has very few patients we believe that, given the results obtained with our flap, it should continue to be used in the future.

 

 

Correspondencia:
Dr. M. Acosta Feria
H.U. Virgen del Rocío
Avda. Manuel Suirot s/n
41013 Sevilla, España
e-mail: Te_ba@hotmail.com

Recibido: 22.09.2005
Aceptado: 04.07.2006

 

 

References

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