Abstract
The aim of this study was to evaluate tongue function in patients with oral cancer treated surgically and reconstructed with anterolateral thigh free flaps (ALTFs). Patients ( N = 238) underwent primary reconstruction after hemiglossectomy between September 2012 and October 2014. Patients were divided into two groups according to the flap design: ‘individual design’ (ABC flap) and ‘common design’. Patients were followed postoperatively and assessed after 6 months for the following functional outcomes: speech, deglutition, tongue mobility, and donor site morbidity. Intelligibility and deglutition were each scored by an independent investigator. Data were analyzed using SPSS version 16.0 software. No differences in mean speech intelligibility scores were observed between the two groups (good: P = 0.908; acceptable: P = 0.881). However, the ABC flap offered recovery advantages for swallowing capacity compared to the common design flap (MTF classification good: P = 0.028; acceptable: P = 0.001). The individualized ABC flap not only provides volume but also preserves mobility, speech intelligibility, and swallowing capacity. ALTFs require further improvement for the individualized functional reconstruction of the tongue after hemiglossectomy, but this work lays the foundation for these improvements.
Functional reconstruction after tumour resection of oral squamous cell carcinoma (OSCC) remains a clinical challenge. Most tongue malignancies involve the anterior two-thirds of the lateral border. Surgery-based sequential therapies are chiefly used to treat cancers of the tongue. Approximately 40% of OSCC patients require some degree of resection. In the past, most oral defects were closed primarily using mucosal or cutaneous local or regional flaps. With the development of microsurgical techniques, microvascular free flaps are considered ideal options for the reconstruction of defects in the head and neck region after tumour resection.
For years, the first choice for restoring soft tissue ablation in the oral cavity was the radial forearm flap (RFF). However, the sacrifice of such an important artery in the hand and the necessity of skin grafting have limited its use. The anterolateral thigh flap (ALTF) was first described by Song et al. in 1984. It is proposed that this flap can be thinned and that a skin graft is not needed. Thus, if used carefully, this modified flap can be used for functional reconstruction after hemiglossectomy.
Current studies indicate that the extent of surgical excision and adjuvant radiotherapy are associated with the severity of functional impairment after OSCC. Also, functional tongue reconstruction is necessary when normal speech and swallowing are seriously affected by oral cavity damage, tongue mobility, speech intelligibility, and palatal contact.
Materials and methods
Patients
Two hundred and thirty-eight patients who underwent simultaneous tumour resection and reconstruction with ALTFs for tongue defects in the department of oral and maxillofacial–head neck oncology of the university hospital of stomatology in Wuhan, China, from September 2012 to October 2014, were enrolled in this study. Upon institutional review board approval, a retrospective review was conducted by an independent investigator. Data were collected on patient age, sex, tumour location, TNM classification, operation time, results of reconstruction, and complications. For each patient, the choice of flap was based on perforators, surgeon experience, the defect size, and patient characteristics.
Surgical procedure
All surgical procedures were carried out using a ‘two-team’ approach: an extirpation team and a reconstruction team. All patients included in this study underwent a subtotal glossectomy, with the resection of at least 50% of the anterior tongue. After completion of tumour resection, the surgeons constructed individually designed ALTFs for functional reconstruction. During preparation, a line was drawn from the anterior superior iliac spine to the superolateral border of the patella (preoperative Doppler examination has shown that the perforators are usually located at the midpoint of this line). Then, after making an incision in the sub-fascial plane to identify the dominant perforators and isolate them, the position of the skin paddle was adjusted. The ABC flap ( Fig. 1 ) was designed for postoperative defects: ‘A’ forms the tip, ‘B’ reconstructs the tongue body and mouth floor, and ‘C’ is used for the tongue root ( Fig. 2 ). The flap was tailored for volume and thickness for each patient.
Postoperatively, flap monitoring was performed by clinical examination, every 30 min for the first 24 h, every 1 h for the second 24 h, and every 4 h over the following days. If necessary, low-dose low-molecular-weight heparin was used as postoperative anticoagulation therapy. Patients were usually discharged between postoperative days 7 and 10, and scheduled for follow-up at 1, 3, and 6 months. For patients with lymph node metastasis, supplemental postoperative radiotherapy was recommended (approximately 60 Gy). No patient was lost to follow-up over the 6-month period.
Functional assessment
Patients in both groups – ‘individual design’ and ‘common design’ – were followed postoperatively to assess functional outcomes regarding speech, deglutition, tongue mobility, tongue shape, and donor site morbidity. Intelligibility and swallowing ability were evaluated by a trained specialist, independent of physician input. The remaining outcome analyses were carried out by an independent investigator to prevent inter-observer bias.
Speech intelligibility
Postoperative speech was evaluated by testing speech intelligibility according to the methods of Hofstetter. The patient’s speech was evaluated during conversation, on a scale of 1–5, based on its comprehensibility. Scores were defined as follows: 1 = speech can be understood distinctly; 2 = speech can be misunderstood occasionally; 3 = speech is understood only when the dialogue conditions are known to the listener; 4 = speech is occasionally understood; 5 = speech cannot be understood completely. Speech intelligibility was classified as good (scores 1–2), acceptable (score 3), or poor (scores 4–5).
Swallowing ability
Swallowing ability was assessed using a Swallowing Ability Scale system (SAS) based on the MTF classification, where ‘M’ is the method of food intake, ‘T’ is the time required for food intake, and ‘F’ is the consistency of the food ingested. Each of these parameters has five subgroups: M5, swallowing ability is unlimited (score of 5); M4, swallowing is unlimited but avoids bucking (score of 4); M3, swallowing is successful when food is in a suitable form (score of 3); M2, a nasal feeding tube is the main means of ingestion (score of 2); M1, nasal feeding is the only method of ingestion (score of 1). The time required for food intake was classified as follows: T5, normal, <15 min (score of 5); T4, 15–25 min (score of 4); T3, 25–35 min (score of 3); T2, 35–45 min (score of 2); T1, >50 min (score of 1). Finally, consistency was classified as follows: F5, if the patient could eat food of any consistency (score of 5); F4, if the patient could eat soft and chewable foods (score of 4); F3, if the patient could eat gruel (score of 3); F2, if the patient could swallow viscous fluids (score of 2); F1, if the patient could swallow non-viscous fluids (score of 1). Swallowing ability was classified as good (MTF score 9–15), acceptable (MTF score 7–8), or poor (MTF score <6).
Statistical analysis
SPSS version 16.0 software (SPSS Inc., Chicago, IL, USA) was used to analyze the data, and a Fisher’s exact test P -value of <0.05 was considered statistically significant.
Results
In this study, 238 patients underwent simultaneous tumour resection and reconstruction with ALTFs. Table 1 shows the patient characteristics. Patients were divided into two groups according to the flap design: ‘individual design’ and ‘common design’. Table 1 gives details of tumour staging and the classification of metastases, and any additional surgery or treatments performed. Flap failure occurred in two cases, for a success rate of 99.2%. Post-surgical sequelae are listed in Table 1 . One patient had a postoperative donor site infection, requiring further debridement. No other complications, including dehiscence, foreign body sensation, and host rejection, occurred during the 1–6-month follow-up period ( Table 1 ).
| Characteristic | ALTF ( N = 238), n (%) | Outcome |
|---|---|---|
| Age, years, mean (range) | 56.5 (21–78) | |
| Male to female ratio, n / n | 89/30 | |
| TNM classification | ||
| T2 | 60 (25.2) | |
| T3 | 112 (47.1) | |
| T4 | 66 (27.7) | |
| N0 | 72 (30.3) | |
| N1 | 125 (52.5) | |
| N2 | 41 (17.2) | |
| Postoperative radiotherapy | 119 (50) | |
| Haematoma | 3 (1.3) | |
| Flap donor site infection | 1 (0.4) | Successful rescue |
| Flap loss | 2 (0.8) | Got better |
| Donor site complications | 0 (0) | Abandoned |
| Tumour recurrence (within 6 months) | 5 (2.1) | Re-operated |
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