Primary Closure

McConnell et al. recently reported on a 10 year prospective multi-institution study of speech and swallowing outcomes following reconstruction of limited tongue resections (14). Pairs of patients within the same surgical resection category were matched with respect to the percentage of oral tongue resected, percentage of tongue base resected, and whether postoperative radiotherapy was given. Three reconstructive methods were analyzed: primary closure, distal (regional) flap closure, and free flap closure. The extent of oral (anterior two-thirds) tongue and base of tongue resected was 5-30% and 5-60%, respectively. An implicit assumption in the study was that all the defects in the primary closure vs. distal flap and primary closure vs. free flap groups were amenable to primary closure. The choice of reconstructive method depended upon the participating institution. Those using distal (regional) or free flaps apparently did so to provide sufficient tissue to separate the floor of mouth from the remaining tongue in an effort to minimize tethering. The study indicates that primary closure resulted in equal or better function than the use of flap reconstruction. Swallowing and speech outcomes do not support the theory that skin flaps or skin muscle flaps (distal or free) enhance function.

Although primary closure will inevitably lead to some degree of tethering of the -g remaining tongue, the use of a flap appears to lead to a greater decrement in speech and swallowing function. Patients with limited tongue defects associated with defects of the floor of mouth may ultimately benefit most by closure of the tongue defect, either primarily or by secondary intention, and reconstruction of the floor of mouth independently using a local, regional, or free flap depending upon the size and adjacent mandibular or pharyngeal defects (Fig. 13). Split-thickness skin grafts provide | ample pliable tissue for resurfacing significant defects of the tongue and even combined defects of the mobile tongue and floor of mouth that are not through-and-through to the neck. The sensations of pain, touch, and temperature return in that

Figure 13 Patient with a significant lateral tongue defect closed primarily with independent reconstruction of the lateral floor of mouth and mandibular ramus (left image: 4-point star denotes lateral tongue defect; 5-point star denotes combined ascending ramus and floor of mouth defects). Image on right shows primary closure of lateral tongue defect with buccinator flap in place over floor and mandibular defects.

Figure 13 Patient with a significant lateral tongue defect closed primarily with independent reconstruction of the lateral floor of mouth and mandibular ramus (left image: 4-point star denotes lateral tongue defect; 5-point star denotes combined ascending ramus and floor of mouth defects). Image on right shows primary closure of lateral tongue defect with buccinator flap in place over floor and mandibular defects.

order to skin grafts. The sensation to touch returns in most patients; however, in approximately 30% of cases there is no recovery of thermal sensation (15).

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