Reconstruction of the Head and Neck $
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Fig. 1.3 Clinical Case. (A) Larger defects that communicate with the neck can be managed with a radial forearm free flap. The skin paddle contours to the alveolus and floor-of-mouth anatomy. (B) The thin, low-profile skin paddle can accommodate a tissue-borne denture.
Surgical Technique and Considerations The radial forearm flap can be designed to the exact dimensions of the floor-of-mouth defect (Fig. 1.3). ◆ The flap can be sutured into the floor-of-mouth defect with absorbable suture. ◆ No bolster is necessary. ◆ The vascular pedicle can be drawn through a floor-ofmouth defect to align the vascular pedicle with a donor vessel for the microvascular anastomosis. ◆
split-thickness skin graft techniques are less desirable because of the inevitable scar contracture that ensues. Primary closure is not usually an option, and therefore free tissue transfer is typically the primary reconstructive option. Select defects can be managed with regional flaps like the submental island flap10; however, one must consider the potential risk of transferring a submental metastasis into the donor site.
Option for Management: Primary Closure Patient Selection and Perioperative Management Patients with larger defects of complex wounds that have been exposed to radiotherapy are ideal candidates for the radial forearm reconstruction. Patients with defects that extend onto the ventral surface of the tongue or lateral tongue are also best suited for this reconstruction. Modifications of this flap, such as inclusion of subcutaneous adipofascial tissue in the distal part of the flap to fill dead space under the floor of mouth,8 or use of a bilobed flap for defects involving the floor of mouth and tongue,9 have been described. Postoperatively, we recommend that the patient be NPO for 5 to 7 days to facilitate healing. Dental restoration should not begin before 8 to 12 weeks when the flap has healed to the deep tissue.
◆ THE PARTIAL GLOSSECTOMY DEFECT
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The partial glossectomy defect can range from a small superficial resection of the lateral tongue to a hemiglossectomy defect. Depending on the size, defects that involve the oral tongue can be managed with a variety of reconstructive options including primary closure, healing by secondary intention, a split-thickness skin graft, a local flap, or a free flap. However, when the floor of mouth is involved in addition to the oral tongue, healing by secondary intention and
In select patients, small defects of the oral tongue can be closed primarily. It is always difficult to exactly determine the threshold for when a defect is best managed with primary closure versus a skin graft versus a free flap. The decision is often based on a combination of experience and instinct. Unlike a skin graft or a free flap, the primary closure technique preserves sensate mucosa, which is helpful in oral rehabilitation (Fig. 1.4). Generally, we suggest that if primary closure appears to tether the tongue from freely moving from side to side, another option should be considered.
Option for Management: Radial Forearm Free Flap The radial forearm remains the optimal donor site for oral tongue reconstruction due to its versatility and often excellent functional results.11 The thin pliable tissue allows for contouring to the oral tongue and the floor of mouth in a way that cannot be achieved with other soft tissue donor sites. Other advantages include the ability to reinnervate the flap to provide sensation.1,12 Some clinicians have criticized this donor site because the thin tissue characteristic of the volar surface of the forearm may be inadequate to provide the bulk necessary to fill a hemiglossectomy defect; however, fat can be harvested from the forearm to adequately provide bulk to the flap.
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