ANTERIOR GLOSSECTOMY:
RECONSTRUCTION WITH A POSTERIOR
TONGUE ROTATION FLAP
MICHAEL FRIEDMAN, MD, and MAlTHEW ROSENBERG, MD
~~
With traditional techniques, reconstructionof the anterior tongue
is often less than satisfactory.The difficulty lies mainly in providing
the tongue with the appropriate amount of bulk essential for nor-
mal movement and function. We present an alternative method
that involves raising a flap from the ipsilateral middle third of the
tongue and rotating it into position for suturing to the anterior
defect border. We have found this simple procedure to yield ad-
equate tongue bulk for normal speech and deglutition. HEAD &
NECK SURGERY 9553-355, 1987
T h e goals of tongue reconstruction after resection
of carcinoma are t o restore normal tongue func-
tion and minimize cosmetic deformity, resulting
in normal speech and deglutition. The techniques
for anterior reconstruction described in the lit-
erature comprise two basic categories. Primary
closure, skin grafting, or ipsilateral hemitongue
advancement are most useful for reconstructing
defects involving 50% or less of the anterior
tongue.',' Total anterior tongue resection requires
either a pectoralis major or sternocleidomastoid
From the Department of Otolaryngology-Head and Neck Surgery, Uni-
versity of Illinois College of Medicine, Chicago. IL, Illinois Section of Oto-
laryngology-Head and Neck Surgery, Illinois Masonic Medical Center.
Chicago, IL (Dr. Friedman); and Metro-Six Program, University of Illinois.
Chicago, IL (Dr. Rosenberg).
Address reprint requests to Dr Friedman at the Department of Otolar-
yngology-Head and Neck Surgery, 1855 W. Taylor Street, Chicago. IL
60612.
Accepted for publication January 13, 1987.
0148-6403/0906/0353 $04.00/3
01987 John Wiley & Sons, Inc.
Anterior Glossectomy
flap for reconstr~ction.~.~ We introduce the pos-
terior tongue rotation flap, a new technique that
we have found to be more practical than existing
procedures in selected cases. Our tongue flap is
unique because it is specifically designed to re-
construct defects involving greater than 50%but
less than total anterior tongue reconstruction. We
have used this flap in three patients, all of whom
have regained normal speech and deglutition.
FLAP DESIGN AND EXECUTION
Carcinoma crossing the midline of the anterior
tongue requires an extended hemiglossectomy
(Figure la). After resecting the tumor, a flap based
on the dorsomedial aspect of the tongue is begun.
An incision is made in the tongue just posterior
to the circumvallate papillae at the base of tongue
and extended laterally. The flap must be begun
just far enough away from the defect to allow ro-
tation into the defect (Figure lb). Since the blood
supply is derived from the floor of the mouth, the
exent of anterior tongue resection does not affect
flap survival. The incision is continued inferiorly
to mobilize the entire segment of flap, which is
then advanced and rotated (Figure lc). Last, the
flap is sutured to the contralateral tongue tip rem-
nant t o close the defect (Figure Id). The final re-
sult is illustrated in Figure le. A 3-0 chromic su-
ture is used for deep closure, mucosal closure, and
donor site closure.
HEAD & NECK SURGERY Jul/Aug 1987 353
FIGURE 1. (a) Portion of the anterior tongue to be resected for carcinoma crossing the midline. (b) After tumor resection, the flap is
begun by making a horizontal incision at the posterior tongue, far enough from the defect to allow for rotation. The incision is continued
inferiorly to moblize the segment. (c) The flap is advanced and rotated into position to fill the defect, and sutured to the anterior border
of the defect (d). The posterior tongue rotation flap is shown sutured in place.

DISCUSSION Ipsilateral hemitongue advancement and sim-

Near total anterior tongue reconstruction as pre-
viously described poses a dilemma. The surgeon
must choose from a variety of techniques, none of
which is exactly ideal for this situation. We pres-
ent another option that may be superior in se-
lected cases.
Primary closure and split-thickness skin graft-
ing are the simplest options available. These pro-
cedures are very effective for repairing small de-
fects, but they result in a tongue that is too narrow
and too short when used for larger defects. Prob-
lems encountered by the patient include pooling
of saliva and difficulty controlling food and fluids.'
Furthermore, the lack of tongue volume results
in phonation characterized by air escape. The ap-
pearance of the tongue is likewise suboptimal.
ilar procedures such as rotation of the contralat-
era1 tongue tip remnant to close the defect are
options most useful for reconstruction involving
up to 50% of the anterior tongue. If only 20% or
less of the anterior tongue remains after resection,
tongue mobility is significantly limited when such
procedures are used.
More extensive procedures such as the pector-
alis major or sternocleidomastoid myocutaneous
flap may also be performed for near total anterior
tongue reconstruction. However, these procedures
are not without significant drawbacks. The pec-
toralis major flap adds too much bulk to the tongue.
Besides limiting tongue movement, this factor
makes subsequent examination difficult. The fat
content is particularly troublesome. The muscle

354 Anterior Glossectorny HEAD & NECK SURGERY JuliAug 1987

mass of the flap can hypertrophy and add even
more volume to the tongue, often necessitating
further procedures for d e b ~ l k i n g .The
~ sterno-
cleidomastoid flap is the most technically de-
manding option because it requires neurorrhaphy
between the spinal accessory nerves to allow for
acceptable tongue m ~ v e m e n t We
. ~ prefer to use
myocutaneous flaps only if the extent of resection
is too great to allow repair by other methods.
Our technique consists of a medially based pos-
terior tongue flap that is advanced, rotated, and
approximated to the contralateral tongue tip. Re-
placement of the defect is therefore accomplished
with the tongue’s own mucosa instead of skin. The
posterior tongue rotation flap is based on the sub-
mental branch of the facial artery, which supplies
blood to the entire flap from the floor of the mouth.6
Thus, its survival is not affected by ligation of the
ipsilateral lingual artery, as previously believed
to be true of dorsal flaps.5 The rich collateral cir-
culation is an additional source of nourishment to
the flap.7
This procedure has yielded excellent results in
our preliminary experience. All three patients
achieved full range of tongue movement and nor-
mal protrusion. The middle third of the tongue
and a portion of its base are slightly narrowed by
this procedure, but function is unaffected. Sensory
REFERENCES
1. Schramm VL, Myers EN: Skin grafls in oral cavity recon-
struction. Arch Otolaryngol 106:258-532, 1980.
2. Hovey LM: Hemitongue advancement following anterior
hemiglossectomy.Plast Reconstr Surg 4:552-555, 1983.
3. Schuller DE: Pectoralis myocutaneous flap in head and neck
cancer reconstruction. Arch Otolaryngol 109185-189, 1983.
4. Conley J, Sachs ME, Parke RB: The new tongue. Otolar-
yngol Head Neck Surg 9058-68, 1982.
Anterior Glossectomy
innervation is not maintained, so initial com-
plaints of anesthesia are comparable to those with
other techniques. None of the patients had prob-
lems with aspiration or difficulty with deglutition.
Speech has been recorded normal, including the
“ S and “T” sounds. In our past experience, pa-
tients who had similar resections repaired with
primary closure had various problems with swal-
lowing and definite speech impediments. Such pa-
tients typically underwent lengthy courses of
speech therapy with only marginal improvement.
No follow-up therapy was required for patients
treated with posterior tongue rotation flaps. Last,
this technique has yielded a superior cosmetic re-
sult over other techniques that we have used.
CONCLUSION
The head and neck surgeon who performs resec-
tion of the anterior tongue should be versed in
different reconstructive techniques. This paper
presents a new option for selected cases. Resection
of small lesions can easily and effectively be
achieved with either primary closure or split-
thickness skin grafting. Reconstruction after
hemiglossectomy is best accomplished with ipsi-
lateral hemitongue advancement. For near total
anterior glossectomy, we recommend reconstruc-
tion with a posterior tongue rotation flap.
5. Mikaelian DO: Reconstruction of the tongue. Laryngoscope
94:34-37, 1984.
6. Klopp CT, Schurter M: The surgical treatment of cancer of
the soft palate and tonsil. Cancer 6:1239-1243, 1956.
7. Sessions DG, Dedo DD, Ogura JH: Tongue flap reconstruc-
tion in cancer of the oral cavity. Arch Otolaryngol 101:
166-169,1975.
HEAD & NECK SURGERY JuVAug 1987 355