Innervated Gracilis Musculocutaneous Flap for Total Tongue Reconstruction
N. J. YOUSIF
W. W. DZWIERZYNSKI
EDITORIAL COMMENT
A number of flaps for reconstruction of the total tongue have been described, and they include— besides the innervated gracilis—the radial forearm, the lateral arm flap, as well as the rectus abdominis. One should not forget that possibly the most important factors for deglutition are the remaining muscles in the undersurface of the resected tongue. Restoration of sensibility should also be an important objective and can be achieved by performing an anastomosis either end-to-end or end-to-side to the lingual nerve.
Reconstruction after total glossectomy is a difficult problem in head and neck reconstructive surgery. The tongue is essential in swallowing, speech, and airway protection (1). Tongue function is achieved by the complex interactions of the intrinsic and extrinsic musculature and their nerve innervation (2, 3). To obtain active muscle function for a neo-tongue, we utilize an innervated transverse gracilis myocutaneous flap. Recreating all the complex motions of the tongue is currently impossible, but the innervated gracilis flap is used in an attempt to recreate one of these functions—elevation (4). Elevation of the neo-tongue can potentially help the glossectomy patient achieve airway protection and improved propulsion of the food bolus.
INDICATIONS
Innervated tongue reconstruction is indicated for total glossectomy defects after cancer extirpation surgery (5, 6). Most conventional tongue reconstructions provide only bulk (7, 8). For partial glossectomy defects, in which some muscle innervation remains, addition of bulk may be sufficient (9). For patients undergoing total glossectomy, innervated gracilis reconstruction offers the cancer patient hope of restoration of some aspects of tongue function.
ANATOMY
The dominant vascular pedicle from the profunda femoris artery to the gracilis enters the muscle 10 cm below the pubic tubercle. The artery at its origin is 1.5 to 2 mm in diameter. It is accompanied by two venae comitantes. The main arterial pedicle divides into three to six vessels, ranging in length between 1 and 2 cm, before entering the muscle. In the upper third of the gracilis muscle, three to six musculocutaneous perforators supply the overlying skin. A septocutaneous perforator can sometimes be found running between the gracilis and the adductor longus muscle. The middle and distal thirds of the skin overlying the gracilis muscle are supplied by vessels from the superficial femoral and saphenous arteries. The unreliability of this distal skin component of the traditional longitudinally designed gracilis myocutaneous free flap has limited its usefulness in the treatment of larger defects (10). Vertical orientation of the skin paddle allows a more robust and reliable blood supply to the cutaneous paddle (11).
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