*4.2.2.2 Free flaps*

*Oral Diseases*

ized flap.

**4.2 Tongue**

*4.2.1 Small defects*

*4.2.2 Larger defects*

*4.2.2.1 Pediculate flaps*

and wound dehiscence [19].

of venous or arterial suffering which may allow an appropriate reoperation in an intent of saving the flap. In the fatal case of flap loss, again it is crucial to retire the dead tissue and if possible cover the defect with a new pediculate or micro vascular-

In the oral cavity the more common defects requiring reconstruction are those from glossectomies. The tongue is a highly functional organ, with a complex muscle mobility that functions as a coordinate unit to articulate words, swallow, and push the bolus back, so the primary goal of reconstruction is to preserve the ability to move it intelligibly and not tethered with adequate soft tissue coverage, avoiding bulky flaps. The three-dimensional oncological resection needs adequate margins up to 1 cm, so the size of the defect may be variable, a quarter, half, near total, or total and can be simultaneously related or not with other structures like the floor of the mouth, cheek, skin, or bone. Based on that, reconstruction may be just a primary closure, a local or a pediculate flap, or a simple or composite free flap.

In cases of small defects up to one-third of the tongue, primary closure could be done (**Figure 4a** and **b**), and if needed, due to a small floor of mouth resection, a skin graft is added in order to avoid a scar combined with tongue fixation. Usually the functional results are optimal, but sometimes skin graft contraction and hyperpigmentation can result, or graft fixation may be inadequate leading to shearing

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

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**Figure 4.**

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

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].
