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Functional Outcomes Following Microvascular Reconstruction of Partial, Hemi, Subtotal, Total, and Composite Glossectomy Defects: A 10-Year Experience
Edward I. Chang, MD, Peirong Yu, MD, Roman J. Skoracki, MD, Matthew M. Hanasono, MD.
MD Anderson Cancer Center, Houston, TX, USA.

PURPOSE: While a number of studies have examined outcomes for microvascular free flap tongue reconstruction, they are often limited by small numbers and short follow-up. Few have comprehensively addressed outcomes based on defect size and location.
METHODS: Retrospective review of all patients undergoing glossectomies from 2000 to 2010 by the senior authors was performed. Patients who underwent a simultaneous laryngopharyngectomy were excluded (partial: n=7; total: n=9). Surgical, oncologic, and functional outcomes were evaluated based on defect size and location.
RESULTS: A total of 241 patients were identified. Defects were classified as partial (n=40), hemi (n=74), subtotal (n=24), and total glossectomies (n=21). Glossectomies performed with mandibulectomies were analyzed separately (partial: n=31; hemi: n=15; subtotal: n=8; total: n=12). Functional outcomes for the 16 patients who underwent a simultaneous laryngopharyngectomy were not analyzed.
There were 269 flaps performed in the 225 patients, with some patients receiving two flaps for reconstruction of composite defects. There were 140 anterolateral thigh flaps (52.0%), 48 radial forearm fasciocutaneous flaps (17.8%), 38 fibular osteocutaneous flap (14.1%), 24 ulnar artery perforator flaps (8.9%), 8 rectus abdominis myocutaneous flaps (3.0%), 5 gracilis myocutaneous flaps (1.9%), 4 lateral arm fasciocutaneous flaps (1.5%), 1 deep circumflex iliac artery osteocutaneous flap (0.4%), and 1 rectus femoris flap (0.4%).
Overall, 53 patients (22.0%) developed perioperative complications. Major complications requiring operative intervention included 18 patients for neck abscesses, 7 neck hematomas, 5 patients for debridement and closure of a fistula, and 8 flap related complications. Three flaps developed venous congestion requiring revision, 4 for debridement of partial flap loss, and there was one total flap loss. Regarding the donor site, there was 1 infection, 4 wound healing complications, 2 hematomas, and 1 seroma.
Speech was significantly impaired by smoking (p=0.016), radiation therapy (p=0.026), composite resections (p=0.001), and larger resections including subtotal and total glossectomies (p=0.004) while innervation improved overall speech function (p=0.026). Swallowing was significantly worse in older patients (p=0.011) and with larger and composite resection (p<0.001) while sensory re-innervation was beneficial (p=0.004). Average follow-up was 33.5 months.
CONCLUSION: Larger glossectomy defects and composite resections result is worse outcomes. While we recommend the ALT flap for larger defects and a forearm based flap for smaller defects, the optimal flap for each defect remains to be elucidated. Comorbidities and the extent and type of resection significantly impair both speech and swallowing; however, reconstruction, particularly with innervated free flaps, still affords the majority of patients with reasonable function that restores their quality of life.


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