Onequarter to Onehalf Glossectomy of the Posterior Tongue

A 48-year-old patient had a T2N0 squamous cell cancer involving the right posterior tongue, tonsil, and mandible. This defect was approximately 3 x 4 cm involving the right base of tongue, tonsillar fossa, and mandibular ramus. The main goal of reconstruction was to provide sufficient bulk so that posterior movement of the tongue would result in contact of this reconstructed segment with the posterior wall and oro-pharyngeal structures to allow sufficient pumping action during the initial reflex swallow. The benefit of sensory reinnervation was dubious.

The solution was to reconstruct the base of tongue and adjacent tonsillar defect with a pectoralis flap. The posterior mandibular defect was bridged with an MRP (Fig. 15). Posterior tongue defects (behind the circumvallate papilla) that encompass up to 25% of its substance can usually be closed primarily or left to close by secondary intention. Surgical exposure for adequate control of tumor margins and primary closure usually requires that a mandibular split be performed. For defects that also include the lateral pharyngeal wall, a vascularized flap (regional or free) should be used (Fig. 16). The critical mass of tongue base that can be removed while still maintaining an intact and functional swallow is unknown. Many variables play a part in determining the final outcome for these patients including their overall health, physiological age, other coincident abnormalities of the oral cavity or larynx, and the type of reconstruction. Primary closure may not be adequate because it is unlikely that exaggerated pharyngeal constriction will be able to compensate and seal the

Figure 15 Composite defect of tongue base, tonsillar fossa, and mandibular ramus shown. Base of arrow marks location of the myocutaneous pectoralis flap paddle; tip of arrow indicates the tongue base defect. The flap paddle is subsequently sutured along the margins of the tongue defect both to reconstruct this structure and to close the through-and-through defect.

Figure 15 Composite defect of tongue base, tonsillar fossa, and mandibular ramus shown. Base of arrow marks location of the myocutaneous pectoralis flap paddle; tip of arrow indicates the tongue base defect. The flap paddle is subsequently sutured along the margins of the tongue defect both to reconstruct this structure and to close the through-and-through defect.

Figure 16 Exposure and primary closure of a 25% loss of the base of tongue performed through a mandibular split approach.

oropharynx. Restoration of bulk, sensation, and coordinated fine motor movement would be ideal. Today, the closest alternative would be an enhanced sensate radial forearm. The forearm flap can be augmented with subcutaneous tissue harvested beyond the skin component in the forearm. This type of reconstruction may help the patient return to a normal diet sooner, especially if the defect extends beyond the base of tongue to involve the epiglottis or pharyngeal wall. A much simpler and effective method for the patient with a substantial base of tongue defect is reconstruction with a pectoralis major flap, as illustrated. Although the flap will have a tendency to migrate inferiorly, this movement will actually increase the bulk and posterior displacement of the tongue without affecting the swallow reflex.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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