Vastus lateralis myofascial free flap in tongue reconstruction.

In the last decade, the antero-lateral thigh free flap (ALT) has become the most popular free flap for tongue reconstruction because of less donor site morbidity and better cosmetic outcomes. However, fascio-cutaneous ALT may be insufficient to reconstruct major tongue defects, while its muscular-cutaneous variant (using the vastus lateralis muscle) may be too bulky. The present study describes our preliminary experience of tongue reconstruction with vastus lateralis myofascial flap, which could potentially offer unique advantages in head and neck reconstruction including adequate bulk when needed, optimal functional results and obliteration of dead space thus preventing fistulas and infections with minimal morbidity. © Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.

Introduction

Nowadays many free flaps have been described and successfully used in oral cavity reconstruction . In the last decade, the antero-lateral thigh free flap (ALT) become the most popular because of less donor site morbidity and better cosmetic outcomes . However, fascio-cutaneous ALT may be insufficient to reconstruct major tongue defects, while its muscular-cutaneous variant (using the vastus lateralis muscle) may be too bulky, especially in patients with a high body mass index (BMI).

The aim of our study was to describe surgical technique and analyze the feasibility of vastus lateralis myofascial free flap (VLMFF) in tongue reconstruction, which to our knowledge has not been reported in the current literature.

Clinical technique

The National Cancer Institute 'Regina Elena' of Rome Ethics Committee approved the pilot study. Three patients affected by tongue squamous cell carcinoma (SCC) were treated from July to October 2015. All patients were staged with biopsy of the tumor, head and neck contrast MRI/CT and PET-CT. All patients underwent a temporary tracheostomy and nasogastric feeding tube placement. In Table I we summarised the patients' clinical data. Reconstructions were performed by VLMFF.

Table I.

Clinical data.

Case	Gender/ age	pTNM	Surgery	Complications	Decannulation/ NG tube removal	Adjuvant therapy
1	F/70	yT2N0M0	Subtotal glossectomy + bilateral ND (I-IV)	None	5/13 days	No
2	M/59	T4N2cM0	Subtotal glossectomy + bilateral ND (I-V;I-IV)	None	8/16 days	Chemoradiation
3	F/69	pT2N0M0	Hemiglossectomy + ipsilateral ND (I-III)	None	4/9 days	No

ND: neck dissection

VLMFF harvesting and insetting

A line was drawn from the anterior superior iliac spine to the lateral border of the patella (Fig. 1a). The incision was made along the aforementioned line between the inferior and superior third. A suprafascial dissection was extended at least 5 cm medially and laterally ligating the skin perforators (Fig. 1b). The intermuscular septum between the vastus lateralis and rectus femoris was visualised and the curved line with lateral concavity, medial to the intermuscular septum, was marked with a surgical pen and incised (Fig. 1c). Fascia was elevated medial-to-lateral to identify the intermuscular septum between the vastus lateralis and rectus femoris (Fig. 1d). The intermuscular septum was then gently dissected and the descending branch of the lateral circumflex femoral artery (DLCF) was identified along with the vastus lateralis motor nerve (Fig. 2a). A fascia paddle was then included over the vastus lateralis exceeding 20% of the desired muscle flap size in all directions (Fig. 2b). VLMFF was raised in a caudal-cephalic direction using a harmonic ultrasonic scalpel (Harmonic Focus, Ethicon Endo-Surgery, Cincinnati, USA) according to the desired shape and respecting the neurovascular pedicle (Fig. 2c). Pedicle dissection continued until adequate neuro-vascular pedicle length was reached (Fig. 2d). Harvesting times were 40, 42 and 47 min, respectively.

Fig. 1.

VLMFF harvesting: a) incision line; b) suprafascial dissection; c) a curved line with lateral concavity is marked with a surgical pen; and d) elevated medial-to-lateral.

Fig. 2.

VLMFF harvesting: a) the descending branch of the lateral circumflex femoral artery is identified; b) a fascia paddle is included over the vastus lateralis; c) VLMFF is raised including an adequate neuro-vascular pedicle; d) VLMFF completed harvesting.

In cases 1 and 3, the DLCF artery was anastomised with the superior thyroid artery, while in case 2 with the facial artery. Venous anastomoses were performed in all cases end to side to the internal jugular vein. Nerve anastomoses between the hypoglossal nerve and vastus lateralis motor nerve was performed in all cases. In Figure 3 we show VLMFF insetting and 30-day post-operative results.

Fig. 3.

Post-operative results: a) VLMFF insetting in patient 2. Tongue reconstruction with VLMFF in patient 2 (b) and 1 (c), 30 days after surgery; d) tongue reconstruction with VLMFF in patient 3, 30 days after surgery.

Discussion

The present study describes our preliminary experience of tongue reconstruction with VLMFF. VLMFF seems feasible, not technically demanding and safe. In our first three cases, we did not experience major complications such as necrosis, local infection or donor site impairment. VLMFF it is not time or budget consuming compared to the fascio-cutaneous and myocutaneous ALT variants since it does not imply further surgical steps and does not require adjunctive preoperative studies . Harvesting of VLMFF required on average of 43 minutes.

VLMFF does not require harvesting of a skin island and consequently does not require preoperative study of vascular anatomy. This results in less closure tension and possibly in less donor site complications and better scar healing. Due to its rich vascular supply, VLMFF does not require any perforator branch dissection either supra/sub fascial or intramuscular. This represents an important advantage since the aforementioned surgical steps imply a higher incidence of flap vascular supply impairment.

VLMFF has also some recipient site advantages. Thanks to the high number of muscular perforators, when the main vascular pedicle is preserved VLMFF could theoretically be shaped freely basing on the reconstruction necessity. However, we should point out that a 20-30% flap mass reduction due to muscular shrinkage should be expected.

Another advantage is represented by the satisfactory cosmetic results. ALT flap classically includes a skin island that is responsible for a certain degree of color mismatch. In VLMFF, the use of muscle implies a better cosmetic result in tongue reconstruction. Moreover, thigh fascia protection adequately prevented fistula development in our 3 patients. A criticism to our technique could be in terms of donor site postoperative morbidity since the vastus lateralis muscle is sacrificed. However, as reported by Hanasono et al. in a series of 220 ALT free flap and later by Bianchi et al. in a series of 98 musculo-cutaneous ALT free flap, the harvesting of the muscular component does not seem to significantly increase donor-site morbidity. Hanasono et al. reported only an 8% of thigh weakness after muscle harvesting that was not associated with the amount of muscle harvested or motor nerve transection. Our 3 patients did not report thigh weakness and did not complain of any limitations in daily physical activity at 30 days after surgery.

Conclusions

The free VLMF flap could potentially offer unique advantages in head and neck reconstruction, including adequate bulk when needed, optimal functional results and obliteration of dead space, thus preventing fistulas and infections with minimal morbidity.