Transverse Cervical Artery Based Free Flap in Reconstruction of a Tongue Defect: A Case Report

Abstract

In the era of reconstructive surgery, new and revolutionary options are being explored in oro-facial defect reconstruction. As free flaps are presently front runners for reconstruction of defects resulting from resection of benign and malignant lesions, there is a need for devising newer options to serve the need of covering defects following oncological resection. The availability of promising pedicles in the supraclavicular region makes it a potential donor site for harvesting regional flaps, and going forward, free flaps. Transverse cervical artery flap has been a useful regional flap for head and neck reconstruction but there are limited literature pertaining to transverse cervical artery free flap. We report a case of successful reconstruction of tongue defect with transverse cervical artery free flap.

Introduction

Oral cavity malignancies are the most common presentation in the head and neck region. Among them, carcinoma of the tongue presents in the highest incidence. Oral tongue is a significant structure of the oral cavity which parts its functions in mastication, speech and articulation, and oral phase of deglutition [1]. Tongue defects resulting from oncologic resection mandate reconstruction. In general, defects less than one-fourth to one-third of the tongue are acquiescent to healing by primary closure, secondary intention, skin grafts or skin substitutes. However, larger defects constituting greater than one-third of the tongue entail reconstruction. The goals of reconstruction would be to replace the tissue bulk, restore anatomic continuity, prevent tethering scars. Reconstruction would depend on numerous factors like size and extent of defect, availability of donor vessels and bone involvement [2].

Reconstruction options for tongue defect reconstruction are multiple, ranging from locoregional flaps to free flaps. Most common locoregional flaps constitute Nasolabial Flap, Facial Artery Myomucosal Flap, Infrahyoid Flap, Submental Flap. Locoregional flaps possess the advantage of single surgical site and shorter operative duration. Nevertheless, these flaps could produce inconsistent results if the pedicle is compromised and pose a challenge in extensive neck disease. Free flaps reconstructive options are Radial artery free flap, Anterolateral thigh flap, and less commonly, Transverse Cervical Artery Free Flap (TCAFF). Both the radial forearm free flap and anterolateral thigh flap are excellent options for tongue reconstruction and have proven successful. However, both options carry inherent limitations pertaining to secondary donor site morbidities, anatomical inconsistencies, and surgical expertise. Although, TCAFF as a reconstructive option has not been tried routinely by surgeons, the inconspicuous scar, single surgical site, and minimal donor site morbidity makes it a competitor for these gold standard options. Additionally, the diameter of donor and recipient vessels are similar. (The diameter of the facial artery ranged from 1.7 to 3.6 mm mean, 2.6 mm and the diameter of the facial vein ranged from 1.8 to 3.9 mm mean, 2.8 mm [3]. The diameter of Transverse Cervical Artery (TCA) is 1.8 to 5 mm, with a mean of 2.5 mm, Transverse Cervical Vein (TCV) varies from 3 to 5 mm and External Jugular Vein (EJV) varies from 4 to 7 mm) [4]. We report a case of successful reconstruction of a tongue defect secondary to oncologic resection, with TCAFF.

Case Presentation

A male patient in his early 40 s presented with a chief complaint of pain on the right side of tongue for 2 weeks. Medical history of the patient was non-contributory. On examination, an ulcero-invasive lesion was noted on the right lateral border of tongue measuring approximately 2 × 1 × 0.5 cm without involving tip of tongue. Tongue movements were unrestricted with no referred pain to ear. On palpation, margins were indurated and tenderness was elicited on palpation. Ipsilateral submandibular lymph nodes were palpable, soft, and mobile.

Investigations and Diagnosis

Routine hematologic investigations were within normal limits. An incisional biopsy of the lesion was performed, which confirmed Squamous Cell Carcinoma—grade II. MRI PNS and Neck revealed an ill-defined, altered signal intensity lesion approximately measuring 2.3 × 1.6 × 1.9 cm over the right lateral border of anterior 2/3rd of tongue with subcentimetric short axis bilateral cervical lymph nodes, largest of which measured 6 mm in short axis diameter at right level I B. Ultrasound guided fine needle aspiration cytology (US guided FNAC) of right level IB lymph node confirmed metastatic deposits. Ultrasonography of the abdomen, computed tomography of thorax and brain confirmed no abnormalities. Clinical TNM staging of the lesion was T2N1M0. As per the staging, the patient was planned for partial glossectomy followed by Selective Neck Dissection (SND Level I-IV) on ipsilateral side and reconstruction with TCAFF under general anesthesia.

Surgical Technique

1. Patient positioning and asepsis

   Under general anesthesia, the patient was placed in the supine posture with the head and neck extended. Appropriate antibiotic prophylaxis was administered and strict aseptic precautions were implemented.

2. Resection of primary tumor and neck dissection

   The primary lesion over the right lateral border of tongue was resected with 1 cm safe margins. SND (I–IV) was performed meticulously, ensuring to preserve the facial artery and external jugular veins which were tentatively selected as the recipient vessels for anastomosis.

3. Reconstruction with TCAFF (Figs. 1, 2, 3, 4, 5, 6, 7, 8 and 9)

   Patient positioning was done by rotating the head to the left side (opposite side of the donor site) with 30-degree shoulder elevation. The course of the TCA was traced and the skin paddle was planned along the TCA's path. The lateral border of the flap was marked 1 cm medially to the acromioclavicular joint, whereas the medial border is marked 1 cm laterally to the lateral border of the sternocleidomastoid muscle. The flap was then progressively and delicately pulled from the muscle using a posterior skin paddle incision, and perforator vessels were identified and isolated by blunt dissection. Wider-diameter perforator vessels were chosen, and the others were ligated to ensure increased flow in the selected vessels. EJV and TCA were identified as potent pedicles and clipped. Anastomosis of EJV was done with Internal Jugular Vein (IJV) (End to side anastomosis) and anastomosis of TCA was done with Facial Artery (End to End anastomosis) and the anastomosed flap was assessed for tissue perfusion and vitality. Bright red, spontaneous bleeding spots confirmed the viability. After achieving adequate hemostasis, number 16 closed suction drain was placed on neck and the donor site was closed primarily.

Fig. 1.

Neck flap and free flap outline marking

Fig. 2.

Final flap outline marking

Fig. 3.

Primary lesion

Fig. 4.

Excised with safe margin

Fig. 5.

Excised specimen

Fig. 6.

Flap harvested

Fig. 7.

Defect in donor site

Fig. 8.

Fully mobilised flap based on EJV and TCA

Fig. 9.

Immediate post op

Outcome and Follow Up

The post-operative phase was uneventful. Patient was administered Injection Clexane 0.6 mg once daily for 3 days and intravenous antibiotics and analgesics for 5 days as per institutional protocol. Drains were removed on post operative day 5 and patient was discharged on day 7. The patient is under regular monthly follow up and the flap is vital (Figs. 10, 11). The patient’s speech and swallow functions are in acceptable limits after 6 months of surgery.

Fig. 10.

7th day post op

Fig. 11.

1st month post op

Discussion

Reconstruction of post resection tongue defect holds an important aspect of speech and swallowing thereby enhancing the patient’s quality of life. Among the options available at present no single flap is considered the best, with each flap having its own pros and cons.

The TCA is situated on an average of 33 mm from the midline, and it branches out from the thyrocervical trunk at the anterior border of sternocleidomastoid muscle, around 17 mm superior to the clavicle, crossing the supraclavicular section of the posterior triangle. As it approaches the anterior border of the trapezius muscle, its trajectory leads it up to 2 cm above the superior border of the middle third of the clavicle. Along the deep surface of the muscle, it follows the spinal accessory nerve before dissipating beneath the anterior border of the trapezius muscle. The TCV is slightly laterally located and frequently separated from the artery and in 30% of the dissections, tiny venae comitantes up to 1.4 mm in diameter are present [5, 6].

There has been much of haze in understanding the pattern and anatomy of the TCA flap. Dating back to history, Lamberty developed the supraclavicular fasciocutaneous flap in 1979 [7]. Later, in 1995, Mizerny et al. did a thorough anatomic analysis that clarified the supraclavicular region's vascularization and highlighted the crucial function of the TCA [8].

Till date, there have been studies stating the perforator version of this flap. This locoregional transverse cervical artery-based flap was first proposed by Ogawa et al. in 2006 [9]. In their anatomical study, the recognized arteriovenous perforator vessels of the TCA supplying the skin of the shoulder, thus confirming the vascularization of a large skin paddle [9]. Luca et al. performed 41 reconstructions of the head and neck region with TCA perforator flap, of which 9.75% of the cases were of the base of tongue. Overall failure rate was 2.43% with total flap necrosis [10]. Wang et al. reported successful reconstruction in 11 cases with TCA perforator flap [11]. Nevertheless, a striking disadvantage of the TCA perforator flap is the limited arc of rotation in order to preserve the pedicle vessels, and the need for prior tissue expansion in order to reach distant sites such as the oral cavity [11]. Consequently, this mandates cumbersome preoperative preparation in order to overcome intraoperative hassles. Thus, in the present case, a free flap based on the TCA was chosen to reconstruct the post resection tongue defect. Moreso, the proximity of the flap to the primary surgical field, makes it esthetically acceptable as well, in addition to bearing an advantage of not requiring grafts to close the donor site.

There is limited literature pertaining to TCAFF. It is a practically feasible option for reconstruction with reliable vascularity. Based on the surgical experience with the present case, the authors suggest that modifications are also possible by incorporating EJV into the flap for venous anastomosis when the option of TCV is not achievable due to any reason. The only noticeable drawback of this flap is that the design of the flap overlaps the deltopectoral fasciocutaneous flap territory, although this can be managed by modifying deltopectoral flap’s design.

Conclusion

TCAFF is a promising free flap for reconstruction of tongue in terms of anatomical robustness, esthetics as well as morbidity. Due to the limited routine use of TCAFF, adequate preoperative planning and evaluation is necessary. Further studies reporting the use of TCAFF for reconstruction of oral cavity defects are required to assess its success rates and complications.

Declarations

Informed consent

Informed written consent has been obtained from the patient.