The aim of this study was to determine whether the islanded facial artery myomucosal flap (iFAMM) is a good alternative to fasciocutaneous free flaps (FCFF) in the reconstruction of lateral oral tongue defects. This was a retrospective study of 40 patients with oral tongue cancers (lateral lesions not >4 cm) operated on between August 2014 and March 2017, who underwent primary reconstruction with either an iFAMM or FCFF. The two groups were compared with respect to intraoperative time, total intensive care unit (ICU) and hospital stay, complications, speech, swallowing, aesthetics, donor site morbidity, and economic feasibility. Patients who had an iFAMM had a reduced operating time, duration of ICU stay, and length of hospitalization; this flap was also more economically feasible. Better aesthetics and less donor site morbidity were also seen. The iFAMM is an alternative to FCFF in the reconstruction of lateral oral tongue defects, as it is less technically demanding, has good aesthetic outcomes, and is more economical, with acceptable donor site morbidity.
The oral tongue plays an important role in speech articulation and the initiation of deglutition. The aims when repairing oral tongue defects following ablative cancer surgery are to restore anatomical form and physiological function. The ideal reconstruction for these defects should be with a flap that provides adequate bulk and pliable tissue, with minimal donor site morbidity. These flaps should also be aesthetically acceptable and economically feasible.
Over the years, reconstruction has evolved from loco-regional flaps such as nasolabial, submental, infrahyoid, and pectoralis major myocutaneous flaps to microvascular free flaps. The radial artery forearm free flap (RAFFF), popularly known as the ‘Chinese flap’, is one of the most commonly used flaps for tongue reconstruction. However, drawbacks include donor site scar, prolonged surgery, and increased financial burden for the patient, among others .
With better understanding of flap anatomy and blood supply, perforator flaps such as the thoracodorsal artery perforator flap, perforator peroneal artery flap, and medial sural artery perforator flap are being used for tongue reconstruction. The lateral arm free flap (LAFF) and thoracodorsal artery perforator flap (TDAP) have the advantages of pliable tissue, a concealed scar, an adequate pedicle length, and a donor site defect that can be closed by primary intention. However, drawbacks include the technically more demanding dissection, small calibre vessels, need to change the patient’s position for the TDAP, and difficulties encountered by the ablative and reconstruction teams working simultaneously.
The facial artery myomucosal (FAMM) flap described by Pribaz et al. is an axial pattern flap . ‘Islanding’ of the flap based on the facial vessels has been used by various surgeons for the reconstruction of diverse oral cavity defects . Despite several advantages, the islanded FAMM flap (iFAMM) is not yet in widespread use. Both the iFAMM and fasciocutaneous free flaps (FCFF) have been used at VPS Lakeshore Hospital, Kochi, India for the restoration of various head and neck mucosal defects. In this context, a comparative study on the utility, advantages, and disadvantages of these flaps was conducted with the aim of determining whether the iFAMM is a good alternative to FCFF in the restoration of lateral oral tongue defects.
Materials and methods
This retrospective data analysis was conducted in the Department of Head and Neck Surgical Oncology at VPS Lakeshore Hospital, which is a tertiary cancer care centre in Kochi, India. Forty treatment-naïve patients with carcinoma of the oral tongue (lateral lesions not >4 cm) underwent wide excision, followed by reconstruction with either iFAMM or FCFF (RAFFF, TDAP, and LAFF) flaps. The study was brought before the ethics committee and clearance was obtained. Lesions involving the ventrolateral surface, tip of the tongue, and floor of the mouth were excluded from the study. The study period was August 2014 to March 2017, with minimum follow-up of 12 months. After obtaining informed consent for the procedure, patients underwent wide local excision of the tongue with adequate margins (with intraoperative frozen section confirmation) and selective neck dissection clearing nodal levels I–IV. No specific criterion was used to assign patients to either of the two flap groups, but elderly patients with co-morbidities were not preferred for FCFF.
Surgical technique for the iFAMM flap
A per oral approach was used to harvest the iFAMM in all cases. The facial artery and vein were preserved during neck dissection. A buccinator myomucosal flap based inferiorly on the facial artery and vein was dissected, islanded on the pedicle, and delivered into the neck medial to the marginal mandibular nerve. This flap was then tunnelled medial to the mandible through the floor of the mouth to restore the oral tongue defect. The average flap size was 6 × 4 cm. The parotid duct was identified and preserved in all cases. The iFAMM flap donor site was covered using a buccal pad of fat and allowed to heal by secondary intention.
The average size of the flap in the FCFF group was 6.5 × 5 cm. A two-team approach was used to perform the reconstruction in this group. The arterial anastomosis was done to the ipsilateral facial artery and the venous anastomosis to the facial vein and/or external jugular vein. A split-thickness skin graft was used for closure of the RAFFF donor site in most cases ( Fig. 1 ). The TDAP and LAFF donor sites were closed primarily.
A tracheostomy was done in most of the FCFF group patients and this was decannulated on day 5 postoperative, while most iFAMM patients were left intubated until day 1 postoperative. A Ryles tube was used for feeding for 5–7 days post-surgery. Mouth opening exercises were initiated as early as 7–10 days postoperative in the iFAMM group.
Data collection and analysis
The postoperative records were used to collect the operating time for flap harvest and anastomosis, total number of days in the intensive care unit (ICU), total duration of hospitalization, need for tracheostomy, postoperative complications, re-exploration, and economic burden. The outpatient records were used for the analysis of speech, swallowing, and aesthetic appearance of the flap (at the recipient site). Morbidity factors for iFAMM (including marginal mandibular nerve dysfunction and postoperative mouth opening) and FCFF (including need for skin grafting at the donor site, hypertrophic scar, altered sensation, loss of the skin graft, and broad scar) were measured. Speech was assessed using the Washington seven-point intelligibility rating scale . Swallowing was assessed using the functional oral intake scale (FOIS) . Longitudinal repeated assessments were done during follow-up. The values obtained at 6 months postoperative were taken for the study. The histopathology report was used to analyse tumour stage, nodal status, and need for adjuvant therapy.
Patient-reported aesthetic appearance at the recipient site was assessed using a visual analogue scale (VAS) ; the score ranged from 0 to 10, with 10 for maximum satisfaction and 0 for minimum satisfaction. Scores were then categorized into poor (0–2), fair (3–5), good (6–8), and excellent (9–10).
IBM SPSS Statistics version 20.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. Qualitative variables were represented using the frequency and percentage. Descriptive statistics such as the mean, standard deviation, minimum and maximum values were done for quantitative (continuous) variables. Fisher’s exact test was used to compare various parameters between the iFAMM and FCFF groups. A P -value of less than 0.05 was taken as statistically significant.
Twenty patients reconstructed with an iFAMM were compared to 20 patients reconstructed with an FCFF, to yield the results reported below ( Table 1 ).
|Variable||iFAMM ( n = 20)||FCFF ( n = 20)||P -value|
|Mean age (years)||51.5||44.7||0.38|
|Mean operating time (min)||56.5||150.5||<0.001|
|Need for tracheostomy||0||14||<0.001|
|Mean ICU stay (days)||1.0||3.2||<0.001|
|Mean hospital stay (days)||7.5||9.4||0.451|
|Intelligible although some differences occasionally noted (score 2)||17||13|
|Intelligible although noticeably different (score 3)||3||7|
|Total oral intake with no restrictions (score 7)||9||12|
|Oral intake with no special preparation, but must avoid specific foods (score 6)||9||7|
|Oral intake of multiple consistencies requiring special preparation (score 5)||2||1|
|Aesthetics (VAS score)||8.4||6.0||0.091|