PhiliPPine Journal of otolaryngology-head and neck Surgery 43
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 23 no. 2 July – december 2008
CASE REPORTS
ABSTRACT
Objective: To present a case of tongue reconstruction using radial forearm free flap.
Methods:
Design: Case report
Setting: Tertiary government hospital
Patient: One
Results: A 52-year-old female with a T3N2cM0 Stage IVa right tongue carcinoma underwent
tracheotomy, right hemiglossectomy with modified radical neck dissection type III and extended
supraomohyoid neck dissection on the left with radial forearm free flap reconstruction. After 1
month, the radial forearm free flap reconstruction in the tongue had acceptable appearance
and good tongue mobility with intelligible speech. The patient did not complain about the
appearance and function of the left forearm.
Conclusion: The radial forearm free flap is a viable reconstructive option for tongue defects
especially where a thin, pliable flap is needed. There is acceptable form and functional restoration
with minimal donor site morbidity.
Key words: radial forearm free flap, tongue reconstruction
A 52-year-old female consulted due to a right lateral tongue mass that was noted 2 months
prior as a 1 x 1cm ulcerative lesion with occasional bleeding and tenderness. The patient was a
non-smoker. Punch biopsy revealed squamous cell carcinoma, well differentiated and surgery
was advised, prompting subsequent admission.
On examination there was a 5 x 4 cm right lateral tongue mass involving a portion of the
tongue base (Figure 1) with no limitation of tongue movement. There were also a 2 x 3 cm slightly
fixed level II lymph node on the right side of the neck and a 1 x 1 cm movable level Ib lymph
node on the left side of the neck. Pre-operative staging was T3N2cM0 Stage IVa. Of the treatment
options recommended, the patient chose surgery with post-operative chemoradiotherapy.
Rodney Oliver J. Aragon,MD1
Samantha Soriano –Castaneda, MD1,2,3
Joselito F. David, MD1,2,3
1 Department of Otolaryngology Head and Neck Surgery
Rizal Medical Center
2 Department of Otolaryngology Head and Neck Surgery
The Medical City
3 Department of Otolaryngology Head and Neck Surgery
Jose Reyes Memorial Medical Center
Correspondence: Rodney Oliver J. Aragon, MD
Department of Otolaryngology Head and Neck Surgery
Rizal Medical Center
Pasig Blvd., Pasig City 1600
Philippines
Telefax: (632) 671 0424
Email: rodneyaragon@hotmail.com
Reprints will not be available from the author.
No funding support was received for this study. The authors
signed a disclosure that they have no proprietary or financial
interests with any organization that may have direct interest
in the subject matter of this manuscript, or in any product
used or cited in this report.
Presented at the Interesting Case Contest (3rd Place),
Philippine Society of Otolaryngology- Head and Neck
Surgery Convention, Baguio City April 2007.
Radial Forearm Flap
for Tongue Reconstruction
Philipp J Otolaryngol Head Neck Surg 2008; 23 (2): 43-45 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 23 no. 2 July – december 2008
44 PhiliPPine Journal of otolaryngology-head and neck Surgery
CASE REPORTS
The patient underwent hemiglossectomy with a portion of the
base of the tongue excised for adequate margins. (Figure 2) The neck
dissection was done simultaneous with the harvesting of the radial
forearm free flap (RFFF). A level IIa lymph node on the right side of the
neck was noted to have extracapsular spread which was adherent to
the anterior scalene muscle.
The cutaneous portion of the RFFF measured 7 x 5cm along with
additional 4 x 5cm ofsubcutaneous tissue. (Figure 3) The donor site was
closed with a split thickness skin graft (STSG). The flap was folded to
simulate the tongue shape and part of the flap replaced the floor of
the mouth. The harvested subcutaneous tissue was tucked in under the
flap to add bulk to the tongue base portion of the flap. (Figure 4) The
radial artery was anastomosed to the superior thyroid artery while the
cephalic vein was anastomosed to the facial vein. The total length of the
operation was 11 hours and 5 minutes.
The patient was decannulated on the 2nd post-operative day and was
started on sterile water on the 6th post-operative day. The nasogastric
tube was removed on the 7th post-operative day and she was discharged
on the 10th postoperative day. Final histopathology revealed tongue
SCCA right, with tumor free margins of resection; metastasis 3 of 32
lymph nodes R (levels 2 and 3); negative tumor involvement, left lymph
nodes.
Concurrent chemo-radiation therapy post-operation was delayed
due to financial difficulties. Four weeks after the operation, there was
note of tumor growth at level II on the right side of the neck. (Figure
5) The RFFF was noted to have good color and the patient had good
tongue mobility. (Figure 6) The patient was on soft diet since she was
edentulous. Speech was intelligible. The patient did not complain
about the appearance or function of the left forearm.
The patient subsequently underwent 60 Grays of external beam
radiation at 2 G per day at standard fractionation for 30 days at 1 month
and 20 days post-operation with erratic compliance. She was asked to
extend her radiotherapy for 10 more days but this was not completed
due to her demise at 3 months and 23 days post-operation.
DISCUSSION
Head and neck oncologists are often confronted with the difficult
challenge of balancing cancer cure and patient survival with preservation
of function, cosmesis and quality of life when recommending the best
treatment option for the patient. This is difficult in the management of
tongue cancer because the tongue is intimately involved in speech and
swallowing. With the introduction of microsurgical free tissue transfer,
the range of tissues that can be transferred for reconstruction of oral
cavity defects has dramatically increased. The radial forearm free flap
(RFFF) has emerged as the option of choice among reconstructive
surgeons for complex head and neck defects after ablative surgery.
Ease of harvest with two synchronous operative teams, potential for
sensory innervation, the thin and pliable skin and fascia obtained and
the pedicle length and caliber of the vessels are among the reasons for
the RFFF’s popularity.1
Meaningful statements about cause and effect relationships
between reconstructive techniques and function cannot be made
Figure 1. Lesion on the right lateral aspect of the tongue
Figure 2. Tongue after glossectomy
Figure 3. Radial forearm flap.
Figure 4. Tongue with RFFF
without accounting for the site and extent of the surgical resection
and many other factors related to the tumor and the patient. There is
also need for development of standardized procedures for evaluating
functional outcome.2 Haughey et al classified tongue defects of
the tongue as hemiglossectomy, three quarter glossectomy, total
oral glossectomy and base of tongue defects. They advocated the
longitudinal fold technique for hemiglossectomy defects. A small
amount of overcorrection about (30%) is needed to allow for decrease
in volume of the flap.3 This is the technique that was used on our patient
to allow for closure of the floor of the mouth defect but at the same
time simulating normal tongue appearance with a thin flap. This was
evident in the acceptable appearance of the reconstructed tongue,
good tongue mobility with intelligible speech and good deglutition of
the patient.
Donor site morbidity is another factor that must be considered in the
patient about the different reconstruction options. A prospective study
on long term functional morbidity of the RFFF donor site revealed 32%
reduced radial nerve sensation, 14% cold intolerance, 14% restriction
of wrist movement and 28% poor aesthetic appearance.4 This was
also confirmed by Toschka et al who opined that it was of no clinical
relevance. In their study, 85.7% of patients displayed optimal functional
hand testing values (80-100%), and 88.6% gave a positive subjective
assessment (80-100%) of postoperative versus preoperative hand
function.2 This was evident in our patient who had slight limitation of
wrist movement which did not hamper her everyday activities.
The reconstruction is fruitless if there is tumor residual or recurrence.
Inspite of advances in surgical ablation and reconstruction, the over-
all survival of patients with advanced head and neck malignancies
has not significantly increased. Thawley and others list the over-all
survival of stage IVa tongue carcinoma at only 34%.5 In the National
Comprehensive Cancer Network Clinical Guidelines in Oncology, the
Figure 6. Recomstructed tongue using the radial
forearm free flap at 4 weeks post-operation.
ACKNOWLEDGEMENT
We would like to thank Dr. Erasmo D.V. Llanes who provided general support and served as our
scientific adviser.
REFERENCES
1. Brown JS. T2 tongue: reconstruction of the surgical defect.Brown JS. T2 tongue: reconstruction of the surgical defect. Br J Oral Maxillofacial Surg.
1999;37:194–199.
2. Toschka H, Feifel H, Erli HJ, Minkenberg R, Paar O and Riediger D. Aesthetic and functional Toschka H, Feifel H, Erli HJ, Minkenberg R, Paar O and Riediger D. Aesthetic and functional
results of harvesting radial forearm flap, especially with regard to hand function. Intern J Oral
Maxillofacial Surg. 2001; 30: 42–48.
3. Skoner JM, Bascom DA, Cohen JI, Andersen PE and Wax M�. Short-Term Functional Donor Skoner JM, Bascom DA, Cohen JI, Andersen PE and Wax M�. Short-Term Functional Donor
Site Morbidity After Radial Forearm Fasciocutaneous Free Flap Harvest. Laryngoscope.
2003;113(Dec):2091–2094.
4. Richardson D, Fisher SE, Vaughan ED and Brown JS. Radial Forearm Flap Donor-SiteRichardson D, Fisher SE, Vaughan ED and Brown JS. Radial Forearm Flap Donor-Site
Complications and Morbidity: A Prospective Study. Plast Reconstr Surg.1997; 99(1):109-115.
5. Thawley SE, Panje WR, Batsakis JG and Lindberg RD. Comprehensive Management of Head and
Neck Tumors. 1999. 34:691-692
6. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology – Head and
Neck Cancers version 2006.
Figure 5. Right side of neck with note
of neck node at level II
management for tongue carcinoma in this stage is excision of the
primary with comprehensive bilateral neck dissection and concurrent
chemoradiotherapy if the nodes have adverse features such as presence
of extracapsular spread.6 Although this would have been ideal for our
case, financial constraints led to delays in adjuvant therapy and limitation
to radiotherapy only instead of concurrent chemo-radiotherapy. This
may have led to the uncontrolled growth of the regional metastasis
and eventual demise of the patient. This is a common plight of patients
in the Philippines wherein much needed health care is not within the
means of most of the population.
The limitation of the study is that we presented only a single case
of tongue reconstruction. An objective assessment of the functional
capability of the reconstruction such as videofluoroscopy or a functional
endoscopic evaluation of swallowing is the ideal but was not done
due to financial and instrumentation constraints. A study comparing
different reconstructive techniques for glossectomy defects matched
by patient factors and extent of defect based on a standardized
functional outcome measure should be done to fully determine the
best reconstructive option for glossectomy defects.
The radial forearm free flap is a viable reconstructive option for
tongue defects especially where a thin, pliable flap is needed. There
is acceptable form and functional restoration with minimal donor site
morbidity.
PhiliPPine Journal of otolaryngology-head and neck Surgery 45
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 23 no. 2 July – december 2008
CASE REPORTS