The first two authors contributed equally to this work.
Tongue reconstruction is challenging with the unique function and anatomy. Goals for reconstruction differ depending on the extent of reconstruction. Thin and pliable flaps are useful for tongue tip reconstruction, for appearance and mobility. This study reports lateral arm free flap (LAFF) as a safe and optimal option for hemi-tongue reconstruction, especially for tongue tip after hemiglossectomy.
Thirteen LAFFs were performed for hemi-tongue reconstruction after hemiglossectomy from 1995 to 2018. Of the 13 patients, seven were male and six were female, age varying from 24 to 64 years.
All flaps healed uneventfully without complications. Donor sites were closed primarily. The recipient vessels for microvascular anastomosis were mainly superior thyroidal artery, external jugular vein. All patients returned to normal diet, with no complaints regarding reconstructed tongue and donor site.
The LAFF is hairless, thin (especially with lateral epicondyle approach), and potentially sensate. They are advantageous features for tongue tip and hemi-tongue reconstruction. Donor site sacrifices the inessential posterior radial collateral artery, and the scar is hidden under short sleeve shirts. We believe that LAFF can be considered as the first choice flap for hemitongue reconstruction, over radial forearm free flaps.
Tongue cancer is the most common oral cancer with reports of incidence of 3.0 per 100,000 individuals [
Current concepts of tongue reconstruction classify tongue defects as hemiglossectomy, subtotal, and total [
Lateral arm free flap (LAFF), first introduced in 1982 by Song et al. [
A retrospective review of 13 patients that underwent hemiglossectomy and hemi-tongue reconstruction from 1995 to 2018 was performed. Demographic and operative data were collected (
A patient is placed in a supine position. The nondominant arm was selected. A line is drawn between the lateral epicondyle and deltoid muscle insertion. The lateral intermuscular septum, located 1 cm posterior to this line, becomes the central axis of the flap. The flap is designed including the axis as circular, bilobed, or elliptical, depending on the defect. In the bilobed design flap, each lobe is used to reconstruct tongue tip defects and mouth floor defects. Design a lobe for the tongue tip defect near the lateral epicondyle to obtain the thinner flap. Incision is made on the anterior margin of the flap. Suprafascial dissection is made until the lateral intermuscular septum, posterior collateral radial artery and its perforators are identified. Muscular perforator branches are ligated. Radial nerve should be preserved, so the posterior antebrachial cutaneous nerve can be used to for sensate flap harvest. Posterior incision of flap is made, flap is elevated. Proximal dissection provides longer pedicle and larger caliber. De-epithelization and defattening is performed according to defect size and flap inset. Donor site is closed primarily. The recipient vessels for microvascular anastomosis were mainly superior thyroidal artery, external jugular vein.
Demographics, defect type, and complications are summarized in
The first case is a 37-year-old male patient who diagnosed recurred tongue cancer (
The second case is a 24-year-old female patient diagnosed with tongue cancer (
Tongue reconstruction is challenging with the unique structure and functions like articulation, deglutition, and taste [
Nowadays, microsurgical advancement has explosively delivered various options like rectus abdominis myocutaneous flap, the latissimus dorsi myocutaneous flap, the RFFF, the ulnar forearm flap, the ALTFF, and the medial sural artery perforator flap. The challenge comes down to perfecting the cosmesis and function, not just replacement of deficient tissue. As microsurgical techniques have developed to a certain level, the nature and innate qualities of flap donor site itself has become the crucial factor that influences the outcome.
Hence, most reports focus on flap selection in regard of tongue defect classification [
Reconstruction of larger defects target for restoring sufficient volume, as even the simplest role of swallowing, oral competence, and macro-aesthetic appearance cannot be accomplished without bulk. Anterolateral thigh (ALT) flaps are popularly used as with its reliability, long pedicle, acceptable donor site mobility, and versatility as perforator flaps or musculocutaneous flaps [
Successful tongue reconstruction of smaller defects depends on thinness, pliability of flap and maintaining tongue mobility. Applying the thinnest possible flap is important because tongue motility comprises of complex arrangements, which is impossible to recreate with musculocutaneous flaps [
Two unsolved drawbacks of RFFFs come from inevitable skin graft for closure and the fact that a major artery (radial artery) has to be sacrificed. Especially, forearm disfigurement has more negative psychosocial impacts in Asian cultures [
LAFF, first described in 1982 by Song et al. [
The unique characteristic of LAFF is the striking thickness difference with 2 mm in the thinnest portion (usually near the lateral epicondyle), 20 mm in the thickest portion (usually near the deltoid region) [
Hemi-tongue reconstruction never requires flap width larger than 7 cm, which allows primary closure of LAFF donor site. Donor site sacrifices the inessential posterior radial collateral artery, and the scar is hidden under short sleeve shirts (
In the past, limitations of LAFF was reported to be sensory loss of donor site, variable anatomy, short and small caliber pedicle. We found these factors to be less highlighted for hemi-tongue reconstruction. Sensory loss of donor site can be prevented through posterior antebrachial cutaneous nerve preservation [
Further issues can expand to sensory aspects of the reconstructed tongue, which is usually often neglected. Currently, there is no consensus on the need for reinnervation of the reconstructed tongue [
Despite the ongoing controversy regarding sensate flaps, Biglioli et al. [
Our study could be limited with the small case number and lack of objective measurements. However, LAFF focused exclusively on hemi-tongue reconstruction with tongue tip included without trouble and complaints is meaningful. Future studies with more attempts of LAFF could further elucidate the safety and optimal qualities.
The underrated LAFF is probably optimal for hemi-tongue reconstructions. Well established advantages like thinness, pliability, hairlessness, potentiality of sensate flap, and availability of primary donor site closure are well applicable, without major vessel sacrifice. Misbeliefs or seemingly disadvantageous characteristics like inconstant anatomy, donor site morbidity, short and small caliber pedicle does not cause any burden in hemitongue reconstruction. We suggest bilobed LAFF design as the 1st choice flap for hemiglossectomy defect reconstruction.
No potential conflict of interest relevant to this article was reported.
The study was approved by the Institutional Review Board of Hanyang University Hospital (IRB No. HYUH 2018-04-009) and performed in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained.
The patients provided written informed consent for the publication and the use of their images.
Case of left hemi-tongue reconstruction using bilobed lateral arm free flap. (A) Preoperative photograph shows biopsy confirmed left tongue cancer. (B) Intraoperative photograph after left hemiglossectomy was performed by the ENT (ear, nose, and throat) department. (C) Intraoperative photograph of harvested bilobed lateral arm free flap. Upper lobe is for the tongue tip and lower lobe for the tongue base. Small yellow background identifies posterior antebrachial cutaneous nerve. Large yellow background identifies posterior radial collateral artery and its vena comitans, which is used as the main pedicle. (D) One-month postoperative photograph. (E) Eleven-month postoperative photograph. (F) Eight-year postoperative photograph shows mucosalization of the reconstructed tongue.
Case of right hemi-tongue reconstruction using bilobed lateral arm free flap. (A) Preoperative photograph shows biopsy confirmed right tongue cancer. (B) Intraoperative photograph after right hemiglossectomy was performed by the ENT (ear, nose, and throat) department. (C) Intraoperative photograph of harvested bilobed lateral arm free flap. Upper lobe is for the tongue base and lower lobe for the tongue tip. Posterior radial collateral artery and its vena comitans are used as the pedicle. (D) Immediate postoperative photograph of the reconstructed tongue. (E) One-month postoperative photograph of the reconstructed tongue.
Primarily closed donor site scar of bilobed lateral arm free flap used for tongue reconstruction, in different periods: (A) preoperative design, (B) 1 month, (C) 7 years.
Demographics, defect type, and surgical procedures of hemi-tongue reconstruction patients
Sex | Age (yr) | Diagnosis | Neurorrhaphy | Recipient vessel | Design | Operation | Complication | Donor site |
---|---|---|---|---|---|---|---|---|
F | 38 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 34 | Hemiglossectomy defect | ○ | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F | 35 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 37 | Hemiglossectomy defect | ○ | Lingual a lingual v | Bilobed | LAFF | None | Primary closure |
M | 35 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F | 41 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 64 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F | 34 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 44 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F | 24 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F | 62 | Hemiglossectomy defect | ○ | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 52 | Hemiglossectomy defect | × | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
M | 62 | Hemiglossectomy defect | ○ | Sup thyroidal a Ext jugular v | Bilobed | LAFF | None | Primary closure |
F, female; M, male; Sup, superior; a, artery; Ext, external; v, vein; LAFF, lateral arm free flap.