Various flap reconstruction options for tongue defect in oral squamous cell carcinoma

Carcinoma of tongue cases is increasing in number day by day. An earlier diagnosis improves a person's chance of surviving five years after being diagnosed with tongue carcinoma. The primary therapeutic option for tongue squamous cell carcinoma is surgery. When evaluating the treatment plan, it is essential to consider the potential effects of such treatments on speech, swallowing, and cosmetic outcomes to get the first-rate loco-regional control rate. Following primary tumor removal, reconstruction should be done expeditiously. The degree of the residual tumor and the type of tongue replacement used to determine how severe the functional impairment will be. In this case series, we attempt to present our institutional data of 142 retrospective cases to highlight various commonly used flaps for tongue reconstruction based on the size of the defect.


INTRODUCTION
Carcinoma of the tongue is a typical head and neck tumour representing approximately 50% of all intraoral carcinoma.About half of all intra-oral carcinomas are defined by it.The lateral margin of the movable tongue is where squamous cell carcinoma most frequently develops (Ligier et al., 2011).
Malignant tongue carcinomas require resection of the lesion with safe surgical margins leading to various defects of different sizes.Smaller superficial tumours can be removed locally and repaired by split-thickness skin grafting, secondary intention healing, or primary closure.If a soft tissue reconstruction is requested, then there are various options to do so.It could be a local, regional or distant flap.Inferior nasolabial flap tunnelled under the mandible appropriate, radial forearm or lateral arm flaps work best for reconstructing more minor posterior tongue lesions.A free rectus flap is frequently used to restore more extensive excisions (75 per cent of the total) (Harrison et al., 2003).

CASE PRESENTATION
We present to you a case series of retrospective data of the last five years (n = 142) cases of oral squamous cell carcinoma with reconstruction options according to their defect size that is presented to our Institute "Datta Meghe Institute of Higher Education and Research, Sawangi, Wardha" at the Inpatient Department of Oral and Maxillofacial Surgery.We have used the Ansarin et al., (2019) classification to divide various tongue defects according to site and size.All patients were Biopsy proven cases of Squamous Cell Carcinoma of the Tongue according to Broder's classification and presented with ulcero-proliferative or proliferative lesions over the right or left side of the Tongue.The clinical, routine blood and radiographic (MRI Tongue) investigation as per requirement was done.The patient was planned for Surgery under General Anaesthesia.For all cases, a suitable Glossectomy was scheduled according to clinical and radiographical findings, suitable neck dissection and reconstruction.All the clinical details are enumerated in (Table 1).

Myocutaneous flap 45
Through this case series, we attempt to present our institutional data and highlight various commonly used flaps for tongue resection based on the size of the defect.We show each pictorial example of every reconstructive option for tongue defect according to size, including primary closure, Islanded Nasolabial Flap Tunnelled under the Mandible, Radial Artery Based Forearm Free Flap, Anterolateral Thigh Flap and Pectoralis Major Myocutaneous Flap (Figure 1, 2, 3, 4, 5).In Al-Halabi, (2018) studied the quality of life between primary closure and free flap reconstruction in tongue cancer patients.
The author came to the conclusion that primary closure helps to keep the residual tongue more mobile, which improves speech.On the other hand, free flap reconstruction enables changes to the remaining tongue's volume and bulk that are necessary to improve

CASE REPORT | OPEN ACCESS
Medical Science 27, e359ms3153 (2023) swallowing.Therefore, while choosing a reconstruction technique for partial or hemiglossectomy defects, primary closure and free flap reconstruction should be taken into account.
A nasolabial flap tunnelled under the mandible (NLFTUM) or a radial forearm flap (RFFF) can be used for hemiglossectomy or compartmental hemiglossectomy reconstruction.Excellent movement is provided by NLFTUM, which is comparable to a free flap.
The tongue's posterior one-third part deformity is adequately covered by its optimum pedicle length.The primary drawback of this flap is a scar that develops after surgery, but this becomes unnoticeable with time (Dupoirieux et al., 1999).To assess the quality-oflife results between RFFF and nasolabial flap in adult OSCC patients, Molly White and Mairi McKinley conducted a study in 2022 (White and McKinley, 2022).The authors concluded that RFFF has more donor site issues than NLFTUM regarding surgical outcomes.However, Free Flap, the Gold Standard, has a superior recovery of speech and deglutition function.
Partial glossectomies caused by defects are frequently plaid with split thickness grafts or largely closed, resulting in either a long, linear lizard tongue or a tiny, rounded tongue that causes speech and swallowing issues.NLFTUM are a straightforward alternative for rebuilding such deformities because they reduce the morbidity associated with problems speaking and swallowing.
It also has the added benefit of covering the defect in hairless skin and lowering donor site morbidity linked to other flaps.It also provides appropriate mass at the recipient site, simplifying postoperative rehabilitation.It is also simple and rapid to harvest, shortening the surgical procedure (Varghese et al., 2001).
The superficial side of the RFFF is a viable alternative due to its anatomical consistency, long vascular pedicle, thick diameter, and ease of cutting.
concluded that the RFFF was superior to the ALTFF for the restoration of hemiglossectomy deficits due to its ability to restore oral functions like chewing, speech, and swallowing.The PMMC flap is a trustworthy, adaptable flap with few donor flaws.
It is the assembly line of pedicled flaps and is still a viable choice when vascularized soft tissue coverage is needed because it is quickly mobilized, technically sound, and straightforward.The standard reconstruction approach for many head and neck abnormalities in the modern era is free tissue transfer.However, due to its speed, the PMMC is still a viable option to consider when vascularized soft tissue coverage is needed (Gangiti et al., 2016).

CONCLUSION
Based on our own experience and the published research regarding the various forms of reconstruction possibilities in tongue cancer assists in supplying the appropriate bulk of tissue with the restoration of speech, swallowing and feeding.A systematic approach of varying flap selections based on diverse tongue abnormalities may generate reliably superior functional and aesthetic outcomes.

Figure 2 Figure 3 Figure 4 of 9 Figure 5
Figure 2 Showing clinical photo of lesion, radiological investigation (MRI), surgical defect of tongue, reconstruction with islanded nasolabial flap tunnelled under the mandible, and follow up photograph (A: Ulceroproliferative lesion present over lateral border of tongue, B: MRI tongue showing extension of lesion, C: Defect created after resection of lesion i.e.Compartmental Hemiglossectomy, D: Reconstruction with Islanded Nasolabial Flap tunnelled under the Mandible, E: 6 months follow up photo)

Table 1
Clinical details and reconstructive options according to defect size of tongue Yuan et al., (2016) technique has significantly improved reconstruction surgery and the ALTFF is quickly becoming a preferred option for uncalcified body tissue reconstruction.InYuan et al., (2016), investigated the oral functioning of tongue cancer patients who had either RFFF or ALTFF.Surgical reconstruction for tongue cancer aims to maximise aesthetic outcomes, provide reliable coverage, and preserve or restore oral functioning.The author concluded that keeping the remaining tongue mobile was crucial when there were partial tongue deformities.The RFFF is more appropriate because a narrow flap is preferable.Increased flap size will impair oral function and restrict tongue motion.For complete or partial glossectomy, the defect is always substantial.
Hence a flap with sufficient mass is needed.It is preferable to use a thicker flap, such as the ALTFF.Research in 2018Yuan et al.,