CASE REPORT

Adipofascial anterolateral thigh free flap for tonguerepair

V. Agostini*, M. Dini, A. Mori, A. Franchi, T. Agostini

Department of Plastic Surgery, University of Florence, C.T.O., Largo Palagi 1, Florence 50139, Italy

Received 24 June 2002; accepted 30 May 2003

KEYWORDSTongue reconstruction;

Anterolateral thigh flap;

Tongue sensitivity

recovery

Summary With the advent of microsurgery fasciocutaneous free flaps have become awell known and accepted option for the repair of tongue defects. Many authors havetried to recover tongue function by modifying this approach. An innovative method forthe repair of tongue defects using an adipofascial anterolateral thigh free flap ispresented in this paper. The results are compared with those of tongue reconstructionsimplementing traditional fasciocutaneous free flaps performed at our institution. Thehistological features of the flaps were investigated postoperatively. Although thispreliminary report has to be confirmed by further experience, it seems to solve manytongue-reconstruction related problems.Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rightsreserved.

The restoration of the function of the highlyspecialised tissues of the tongue is one of thegreat challenges for the plastic surgeon. Until theadvent of microsurgery, patients with major tonguedefects were treated with local flaps1 and later byregional fasciocutaneous, muscular and myocuta-neous flaps.2 –5 In the past 15 years, the fasciocu-taneous forearm free flap has been the flap mostused for tongue reconstruction. Its pliability andthinness make it ideal for use in oral cavitydefects.6 –9 In some cases, the reconstruction ofmore than half a tongue has been attempted usingthe reinnervated rectus abdominis myocutaneousflap. However, no taste sensitivity can be recoveredusing these flaps and protective sensation recoverynever reached a satisfying level.10 In the last 10years, the anterolateral thigh flap, first reported by

Song et al.,11 has come into popular use.12 Thisarticle puts forth a new approach to tonguereconstruction using an adipofascial anterolateralthigh flap.

The British Association of Plastic Surgeons (2003) 56, 614–618

S0007-1226/03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S0007-1226(03)00204-2

Fig. 1 The carcinoma of the right border of the tongue.*Corresponding author. Tel.: þ39-05542-78292; fax: þ39-

05542-78099.

Fig. 5 (A–B) Comparative histological views with hema-toxylin and eosin coloration of the tongue (A) and the flap(B).

Fig. 2 The flap risen from the right thigh. The whitearrow shows the pedicle.

Fig. 3 The flap inset in the oral cavity with its fascialsurface outwards.

Fig. 4 Result after 45 days.

Adipofascial anterolateral thigh free flap for tongue repair 615

Case report

In May 2001, a 50-year-old man presented with asquamous cell carcinoma of the mobile right tongueborder (Fig. 1). Clinical examination of the neckwas negative. The patient underwent resection ofthe mobile right half part of the tongue withconservative neck dissection. A 13 £ 6.5 cm2 ante-rolateral fasciocutaneous thigh flap supplied by an8 cm vascular pedicle was harvested from the rightleg (Fig. 2). During the procedure, the flap wasconverted into an adipofascial flap, the skin excisedand trimmed to fit the tongue defect. Then the flapwas sutured to the residual tongue in a reversefashion with the fascial surface outward. The arteryand vein were anastomosed end to end to thesuperior thyroid artery and the external jugular vein(Fig. 3). The thigh defect was closed directly.

The 13th day after surgery, the patient had apulmonary embolism due to left popliteal veinthrombosis and underwent thrombolitic therapy.Regarding the reconstruction, no surgical compli-cation occurred in the postoperative period. Thedonor site wound healed uneventfully. The patientwas discharged with a soft diet on day 30. Hisspeech was rated intelligible. Forty-five days aftersurgery the clinical aspect of the reconstructedtongue was identical to the residual tongue. Itsmobility was limited in tip protrusion, but it wasable to transfer a bolus to the pharynx at will, andthe patient did not require head-tilting to swallow(Fig. 4). The hot and cold and touch sensitivity ofthe neo-tongue did not differ from that of theresidual tongue and even taste sensitivity wasrecovered. The physical aspect of the flapresembled that of a normal tongue with tastebuds covering the mucosa. The result of the biopsyof a specimen of the neo-tongue compared to thebiopsy of the residual tongue did not show anyrelevant difference. Both specimens showed asquamous epithelial lining, and a mild inflammatoryinfiltrate was present in the lamina propria (Fig. 5).Small stromal nerve structures were detectable inboth biopsy specimens using an immunohistochem-ical staining for S-100 protein (Fig. 6).

Discussion

Since the era of microsurgery, many surgeons focuson restoring the tongue’s sensitivity and mobility.8,

10,13 –16 However, taste sensation has never beentested because the flap’s epithelium lacked thetaste buds which cover the tongue mucosa. In somecases, a mucous membranous metaplasia of the

Fig. 6 (A–B) Comparative histological views of thetongue (A) and the flap (B) using an immunohistochemicalstaining against S-100 protein.

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fasciocutaneous flap used for tongue reconstructionhas been observed one year after surgery, but therewas no regeneration of taste buds and the patientwas unable to recognise taste on the flap.17 Thetransfer of free microvascular jejunal patches wasattempted to reproduce a mucous producingmucosa, but its harvest is complicated whencompared with the fascial flaps.18

The idea of using fascial flaps for oral cavityreconstruction is not new.19 – 21 Many authorsstudied the remucosalisation of the myofascialpectoralis major flap used to cover oral mucosadefects and their histological results showed thatthe flap was covered with a thin layer of squamousmucosa 1 month after surgery. This result was notinfluenced by the subsequent radiotherapy treat-ment.22,23 Later, when the practice of using afasciocutaneous radial forearm free flap for oralcavity reconstruction was well established, the ideaof fascial flap prelamination was proposed,24 butdelayed tumor resection should usually be avoided.

At our institution, we used to perform tonguereconstruction using the forearm free flap accord-

ing to Soutar’s technique. All cutaneous flaps givethe tongue a patching aspect since their surfacecontinues to be constituted by a hairy keratinizedepithelium. In two cases, forearm cutaneous flapsresembled a normal tongue due to their pinkishcolor three months following surgery (Fig. 7).Radiotherapy was administered to both patients inthe post-op period and the biopsy of the flapsshowed the presence of inflammatory cells in thecontext of a keratinized epithelium, but no mucosaregeneration was observed.

We chose the anterolateral thigh free flap fortongue repair because of the low morbidity of thedonor site. When excising the skin from the flap, wefound the thick and strong fascia an ideal field forallowing the lingual mucosa to spontaneouslyregenerate, avoiding the patching aspect of thecutaneous flaps, and obtaining better functionalresults.25 Moreover, the flap can be thinned as far asit fits the tongue defect with no risk.

Although the results of this case must beconfirmed by further experience, this studysuggests a new approach to tongue reconstruction.

References

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Fig. 7 Normal tongue appearance of the forearm freeflap used for tongue reconstruction after radiotherapytreatment.

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