*4.2.2.1 Pediculate flaps*

In a bigger defect up to half of the tongue or particularly in a huge composite defect that may include the floor of the mouth, cheek, or both, a pediculate and free flap are the alternatives preferred. In a defect up to 6 or 7 cm, the pediculate submandibular flap can be harvested and is my first choice as long as the neck is N0 or N+ with no fixed nodes and small metastatic nodes (**Figure 5a** and **b**). It usually provides a non-bulky flap that can be harvested to cover the defect and can be tied to the tongue to allow mobility for swallowing and speech [20–21]. In cases of N2 neck with huge or fixed metastatic nodes that impacts the possibility of preserve the submandibular pedicle, a supraclavicular pediculate flap can be harvested specially

**149**

*4.2.2.3 Alternative options*

*Modalities and State of Art in Oral Cancer Reconstruction*

to reconstruct tongue with a composite cheek defect [22]. This flap previously described, is also recommended in cases when a free flap cannot be performed due to any specific contraindication such as inexperience or lack of a reconstructive team in microvascular surgery or if the patient is in a poor physical condition and a

In cases of a near total or total glossectomy that frequently is associated with composite resections of the floor of the mouth, cheek, skin, or mandible, a free flap is required (**Figure 6a**–**c**). Speech and swallowing functions after reconstruction for those defects remain disappointing due to the reduced mobility of the flap and the poor functional muscle quality, therefore, the more tongue musculature left, the better rehabilitation of speaking and swallowing will be achieved, and of course, a better functional outcome. The reason for that is that the coordinate movement of the tongue cannot be replaced and the new tissue attached to the rest of the tongue relies on its mobility and just leaves a bulk. If sensation is attempted, a sensory nerve reconstruction provided by the free flap should be intended at the time of reconstruction. If a total glossectomy is performed, the main goal of reconstruction is to provide an adequate amount of soft tissue and bulky flap to allow the neo-tongue to get in touch with the palate to push food toward the hypopharynx and in some way to help in speech [24]. Nevertheless, normal movement will not be accomplished, fundamentally affecting speech and articulation. If only soft tissues are essential, a radial forearm free flap (RFFF) or an anterolateral thigh flap (ALTF) (**Figure 7a** and **b**) are the first option to reconstruct the defect, both of them provide a good amount of soft tissue that can be sentient, just to fulfill the objective mentioned before. The use of free flaps to transfer muscle to achieve motor innervation of the neo-tongue, like the latissimus dorsi or gracilis free flap

has been intended with disappointing results in terms of function [25].

For selected patients in whom free tissue transfer is not an option, the pectoralis major myocutaneous flap offers a reliable reconstructive procedure following both

*DOI: http://dx.doi.org/10.5772/intechopen.91049*

shortened procedure is mandatory [23].

*(a) Submandibular flap harvest and (b) submandibular flap insetting.*

*4.2.2.2 Free flaps*

**Figure 5.**

**Figure 4.** *(a) Primary closure and (b) primary closure outcome.*

**Figure 5.** *(a) Submandibular flap harvest and (b) submandibular flap insetting.*

to reconstruct tongue with a composite cheek defect [22]. This flap previously described, is also recommended in cases when a free flap cannot be performed due to any specific contraindication such as inexperience or lack of a reconstructive team in microvascular surgery or if the patient is in a poor physical condition and a shortened procedure is mandatory [23].
