Superficial circumflex iliac artery perforator flap for tongue reconstruction after hemiglossectomy for cancer: A case report

Abstract

We report a case where a superficial circumflex iliac perforator (SCIP) flap is used to reconstruct the tongue of the patient with half-tongue defects after tongue cancer surgery at the Hue Central Hospital (Hue city, Vietnam). The patient did not have any fluid retention, wound infection, or bleeding after surgery, and the flap survived well. The inserted nasogastric tube was removed ten days after the reconstruction, and the patient was discharged after two weeks. Postoperative functional (speech, swallowing) and tongue aesthetic assessments (symmetry) revealed significant improvement after 1, 3, and 6 months. The SCIP flap can be considered by skilled reconstructive surgeons for patients with major flaws in the tongue and floor of the mouth, and it ensures both functional and aesthetic benefits for the reconstructed tongue, with minimal scarring of donor site. The disadvantages of the flap include the moderate length of the pedicle and small diameter of the arteries and veins.

Highlights

  • Hemi-tongue defect after excision of a well-differentiated squamous cell carcinoma.

  • Tongue reconstruction with the superficial circumflex iliac perforator (SCIP) flap.

  • Good functionality as well as aesthetic of both the tongue and of the donor site.

  • SCIP flap is a choice for large defects of the tongue and the floor of the mouth.

Introduction

The tongue is the first part of the digestive tract, and tongue cancer is the most common cancer of the oral cavity [ , ]. The disease progresses locally, rarely metastasizing distantly [ ]. Surgery and radiation therapy are still the main treatment modalities for primary tumors and regional lymphoma. The total survival rate after 3 years of stage I/II cancer is 70.9% and stage III/IV is 28.8% [ ]. Combining surgery with radiotherapy is the standard treatment for severe conditions. Clinically, surgery is the method of choice [ , ].

Hemiglossectomy is the major mode of primary tumor resection in most cases [ ]. The resection results in a defect that is quite large, affecting the speech and deglutition function of the patient after treatment. There are many reconstruction methods for tongue defects. According to the stepwise regeneration technique, suturing, skin grafting, and using local flaps are only suitable for small defects. For half-tongue defects, two types of flaps are considered effective: the regional and free flaps. We tried to use the regional flaps for reconstruction. However, these flaps were associated with many disadvantages related to their thickness and volumes. Therefore, free flaps are still the comprehensive choice for major tongue defects [ ].

Many previous studies have shown that shaping with a radial forearm free flap (RFFF) or anterolateral thigh flap (ALT flap) is a guaranteed treatment for cancer, which also restores the function and aesthetics of the tongue [ , ]. These flaps are also heavier and can necessitate additional debulking procedures. Another drawback is that donor site scars on these flaps can be unsightly or impossible to conceal [ ]. However, the superficial circumflex iliac perforator (SCIP) flap has more advantages compared to the aforementioned flaps. The SCIP flap, like the traditional free groin flap, is based on the superficial circumflex iliac artery (SCIA). Koshima et al. first documented the use of a SCIP flap in 2004. The flap was then used for reconstructing the limbs and genitals. However, there have been relatively few records of its use in the head and neck area [ ].

The donor site is much more veiled than the widely used ALT flap site, and an ultra-thin skin flap may be acquired and used during the resection stage. As a result, the SCIP flap is an ideal thin, pliable, and dependable skin flap for reconstructing small intra-oral soft-tissue defects, especially in women, without comorbidity [ ]. Therefore, we used this flap to reconstruct the tongue in patients with tongue defects after hemiglossectomy, at our hospital.

Case report

A 56-year-old female patient was hospitalized for experiencing pain while swallowing. During the examination, a tumor was found in the right side of the tongue ( Fig. 1 ). Biopsy of the tumor revealed the following pathological results: well-differentiated squamous cell cancer and invasive keratosis. No abnormal observations were made during laparoscopy and endoscopy. A whole-body computed tomography scan revealed a tumor on the right side, with soft tissue density; uneven margin; size, 22 × 11 mm; strong and heterogeneous drug infusion after injection; no invasion into the oral floor, bone, or right cervical lymph node; and no distant metastasis.

Fig. 1
Preoperative photograph showing the tumor.

The patient was diagnosed with squamous cell cancer in the right side of the tongue, T2N0M0 according to the Eighth Edition AJCC Cancer Staging Manual [ ], and treated by hemiglossectomy of the right floor of the mouth, resection of the right cervical lymph node, and reconstruction with SCIP-type free flap.

The summary of the surgical procedure: (1) under endotracheal anesthesia, a stomach tube was inserted; (2) after performing tracheostomy, a size 7.0 endotracheal tube was inserted through the tracheal opening; (3) groups I, II, and III lymph nodes of the right neck were resected, the submandibular gland was removed, and the facial artery, superior thyroid artery, and veins in the neck of the patient were preserved; (4) teeth #4.1 to #4.5 (from the lower right central incisor to the lower right second premolar) were extracted and the mandible was lowered to the position where the teeth were extracted; (5) a part of the tongue—the oral floor with the tumor was removed and the lesion with its margin at least 1 cm away from the tumor in 3-dimension was resected ( Fig. 2 ); (6) before using the flap, doppler ultrasound was used to find the superficial circumflex iliac artery and the size of the flap was determined by measuring the edges of the defect; (7) SCIP flap, 12 × 5 cm in size, was used and its pedicle included the perforation branch of the superficial circumflex iliac artery and the superficial vein system ( Figs. 3 and 4 ); (8) the flap was placed in the oral cavity and positioned on the remaining portion of the tongue; (9) blood vessels were connected before transferring the flap. Connections were made by end-to-end anastomosis performed on the facial artery and vein ( Fig. 5 ); (10) The tongue-mouth floor was sutured, the drainage was placed, and the wound in the neck and groin area was sutured. To end the procedure, we replaced the endotracheal tube with a 2-branch cannula 7.0 cuff.

Fig. 2
Gross pathology shows groups I, II, and III lymph nodes of the right neck, the submandibular gland, and a part of the tongue—oral floor with tumor after resection.

Jun 12, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Superficial circumflex iliac artery perforator flap for tongue reconstruction after hemiglossectomy for cancer: A case report
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