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SURGICAL ONCOLOGY AND RECONSTRUCTION

J Oral Maxillofac Surg70:2440-2444, 2012

Sliding Anterior Hemitongue Flap forPosterior Tongue Defect Reconstruction

David K. Lam, DDS, PhD,* Allen Cheng, DDS,†

Karim E. Berty, DDS, MD,‡ and

Brian L. Schmidt, DDS, MD, PhD§

Posterior tongue defects present a unique reconstructive challenge. The various reconstructive optionsavailable for treating the defect created by a posterior hemiglossectomy frequently result in a distortedtongue and functional impairment. This paper describes a novel sliding anterior hemitongue flap to allowreconstruction of moderate resection defects (i.e. for T1-T2 tongue squamous cell carcinomas) of theposterior tongue. By mobilizing the anterior tongue, near normal mobility and tongue length aremaintained. This surgical technique may be performed alone intraorally or in combination with a neckdissection.© 2012 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 70:2440-2444, 2012

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efects of the posterior tongue present a uniqueeconstructive challenge. Surgical treatment of T1r T2 squamous cell carcinoma involving the pos-erior third of the tongue involves removal of theosterior half of the involved side of the tongue.fter posterior hemiglossectomy, primary closuref the remaining tongue or skin grafting of the rawurface frequently results in a distorted tongue that isoo short or too narrow. These patients may also com-lain of salivary pooling, food trapping, and inefficient

Received from the Department of Oral and Maxillofacial Surgery,

University of California, San Francisco, CA.

*Postdoctoral Scholar and Former Maxillofacial Oncology Fellow,

Department of Oral and Maxillofacial Surgery, University of Califor-

nia, San Francisco, CA.

†Chief Resident, Department of Oral and Maxillofacial Surgery,

University of California, San Francisco, CA.

‡Former Chief Resident, Department of Oral and Maxillofacial

Surgery, University of California, San Francisco, CA.

§Professor, Department of Oral and Maxillofacial Surgery and

Director, Bluestone Center for Clinical Research, New York Uni-

versity, New York, NY.

Conflict of Interest Disclosures: None of the authors reported

any disclosures.

Address correspondence and reprint requests to Dr Schmidt:

Bluestone Center for Clinical Research, New York University Col-

lege of Dentistry, 345 East 24th Street, Clinic 2W, New York, NY

10010; e-mail: bls322@nyu.edu

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7010-0$36.00/0

toi:10.1016/j.joms.2011.11.005

2440

ongue control of food and liquids in the posterior oralavity. By reconstructing a full-bodied, mobile posteriorongue, these problems may be prevented.

This report describes a novel sliding anterior hemi-ongue flap to allow reconstruction of moderate re-ection defects (ie, for T1 or T2 tongue squamous cellarcinomas) of the posterior tongue. By mobilizinghe anterior tongue, near normal mobility and tongueength are maintained. This surgical technique may beerformed alone intraorally or in combination with aeck dissection.

Surgical Technique

The tumor is resected in the usual manner and aneck dissection may be performed concomitantly,if indicated. Tumors with a surface dimension of 2to 4 cm with a 1- to 2-cm margin will result in adefect of 4 to 6 cm. An adult tongue has a length of12 to 14 cm when fully protruded.1 As such, theemaining ipsilateral tongue would have 6 to 8 cmf remaining usable tissue. The anterior tongue maye readily mobilized, rotated, and moved posteri-rly to reconstruct a full-bodied tongue. After pos-erior hemiglossectomy, the median fibrous septumf the remaining tongue is divided down throughhe genioglossus muscle, carrying this division an-eriorly to the anterior third of the tongue (Fig 1A).ecause the lingual neurovascular supply is found

aterally and the median fibrous septum contains noajor vessels,2 dividing the remaining tongue into sep-

rate halves is rapid, safe, and almost bloodless. With the

ongue divided, a curvilinear incision is extended to the

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LAM ET AL 2441

contralateral anterior tongue (Fig 1B) to facilitate pri-mary closure and minimize tongue tip deviation. Theremaining anterior half of the ipsilateral tongue isthen easily rotated along the curvilinear incision andmoved posteriorly to be sutured to the posterior thirdof the tongue (Fig 1C). These areas may be closedprimarily (Fig 1D) because of the mobile mucosa ofthe ventral surface of the tongue and adjacent floor of

FIGURE 1. Sliding anterior hemitongue flap surgical technique.hrough the genioglossus muscle and carried forward to the anterioro the contralateral anterior tongue (red dashed line). The remaininincision, moved posteriorly (arrows), and D, sutured primarily to th

Lam et al. Novel Sliding Anterior Hemitongue Flap. J Oral Maxil

the mouth.

A clinical case is presented to illustrate the sur-gical technique. An 85-year-old woman presentedwith a 2-cm (T2N0M0) squamous cell carcinomainvolving the posterior right lateral border of thetongue (Fig 2A). She underwent ipsilateral neckdissection and a wide local excision with a 1.5- to2-cm margin of normal tissue, leaving approxi-mately 1 cm of the ipsilateral posterior tongue base

median fibrous septum of the remaining tongue is divided downf the tongue (dashed red line). B, A curvilinear incision is extendedior half of the ipsilateral tongue is C, rotated along the curvilinearerior third of the tongue.

urg 2012.

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and most of the ipsilateral anterior half of the

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2442 NOVEL SLIDING ANTERIOR HEMITONGUE FLAP

tongue intact (Fig 2B). The anterior half of thetongue was then divided into 2 halves by incisingcompletely through the median raphe with a curvi-linear incision extended to the contralateral side(Fig 2C). The ipsilateral anterior half of the tonguewas then rotated, moved posteriorly, and sutured tothe posterior tongue (Fig 2D). Postoperative pho-tographs were taken 1 year later (Fig 3). The patienthas a full-bodied tongue in the posterior oral cavityand shows excellent tongue mobility with goodpremaxillary contact, tongue elevation, and tongueprotrusion. Speech is intelligible and articulate,with good production of ta, cha, and ka sounds.wallowing is normal, as is the control of saliva andood in the posterior oral cavity.

Discussion

To date, the various reconstructive options for

FIGURE 2. Clinical case illustrating the sliding anterior hemitongosterior one third of tongue (inset, surgical specimen). B, Appea

ongue is divided through the median fibrous septum with a curvilinf the tongue after hemitongue advancement with primary closure

am et al. Novel Sliding Anterior Hemitongue Flap. J Oral Maxil

treating the defect created by a posterior hemiglos- fi

sectomy include 1) primary closure of the dorsal tohe ventral tongue surface; 2) allowing the raw sur-ace to granulate and re-epithelialize secondarily; 3)kin grafting of the raw surface of the tongue;3 3)

various pedicled flaps;4-6 and 4) various free tissuevascularized flaps.7-20 Except for very small defects,hese methods are often associated with tongue de-ormity, inefficient control of saliva and food, an ab-ormal appearance, or possible donor site morbidity.After a posterior hemiglossectomy, a significant

ortion of the anterior tongue remains available to beotated and moved posteriorly. This simple surgicalechnique allows restoration of a full posterior tonguey a sliding anterior hemitongue flap. The lateral ori-ntation of the lingual neurovascular supply allowsivision of the remaining tongue down through theedian fibrous septum in a safe and rapid manner.oreover, because no large vessels cross the median

surgical technique. A, T2N0M0 squamous cell carcinoma of theof the tongue after posterior hemiglossectomy. C, The remainingision that is extended to the contralateral anterior tongue. D, View

urg 2012.

ue flapranceear inc.

brous septum, this dissection causes minimal blood

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loss. The ipsilateral anterior tongue is then easily rotatedand moved posteriorly to be sutured to the remaining

FIGURE 3. Posterior hemiglossectomy patient 1 year after slidinganterior hemitongue flap reconstruction. The patient has a func-tional and full-bodied tongue in A, the right lateral excursion, B, atest, and C, the left lateral excursion.

am et al. Novel Sliding Anterior Hemitongue Flap. J Oral Max-llofac Surg 2012.

posterior tongue. In addition to applications after pos-

terior hemiglossectomy, this surgical technique may beapplied to a situation in which a large posterior tongueflap is to be used for intraoral reconstruction.

As with any significant surgery of the tongue, there ismarked lingual edema for the first 48 to 72 hours post-operatively. During this time, the patient must be main-tained initially on intravenous fluids and, when toler-ated, fed through a nasogastric feeding tube placed atthe time of surgery. As soon as the edema begins toresolve, oral feeding is progressed. When healing iscomplete, the patient is left with a full-bodied, mobiletongue that allows normal speech, food control, andtongue excursions. Swallowing remains undisturbedand the tongue is normal in appearance.

A simple technique has been described that will re-store a full-bodied, mobile tongue after a partial poste-rior hemiglossectomy. The procedure is applicable afterresections of stage 1 cancers of the posterior tongue. Itcan also be of value when a large posterior tongue flaphas been used for intraoral reconstruction.

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