When I realised I’d have to have a hemi-glossectomy (half my tongue removed) I was relieved to hear that the missing bit of tongue could be replaced by a flap of tissue from my arm. Phew! There wouldn’t be a gaping hole and the remaining part of my tongue could push the flap around to enable me to talk.
This flap surgery is well known to vast numbers of head and neck cancer patients but the rest of the world knows little about it and even GPs seem confused. Twice I’ve been to different GPs on duty after a big surgery and they have said, “I don’t know what I’m looking at.”
This article, a patient’s record, is about the “free flap”, tissue taken from elsewhere in the body to fill a defect in the head and neck. What I didn’t know in those early days is that the flap of tissue (because it is big) has to have a blood supply. A “pedicle” (a long attachment) of vein and artery is removed from the graft site with the other tissue.
Many head and neckers have had tongue cancer and will be familiar with the tongue surgery to remove the tumour, the removal of a square hunk of tissue from the inside wrist plus a long string of blood vessels. They will have the raw wound from this graft site covered with a thin peeling of skin from the front of the thigh – the donor site.
This is big complex surgery and takes a team, including a head and neck surgeon and a plastic or reconstructive surgeon. It can take 8 hours or so on the operating table and the patient will probably need a temporary tracheostomy so they can breathe while the tongue settles down again.
There will probably be a neck dissection to remove lymph nodes along the side of the neck from below the ear to below the chin. The blood vessels from the forearm flap are joined to blood vessels via this cut in the neck. (I’m getting to the limit of my understanding here.)
However, if it goes well, it can give the patient an acceptable quality of life. There’ll be some change in speech sound but the speech should still be clear. The scars will never go away but after a year they are acceptable. You have a wide pink patch on your inner wrist with a long thin scar where the blood vessels were harvested. There’ll be a large square white wrinkly patch on your thigh where the skin to cover the wrist was taken.
Patients sometimes get a sort of “turkey neck” from the neck dissection where the scarred side of the neck of an older person is firm and the looser skin on the good side spills out annoyingly on the other side of the scar.
These side effects were bearable for me and I have never felt any discomfort from my flap. My speech has a slightly unpleasant nasal quality. I suppose it sounds as if I have something in my mouth – which I have! A doctor called it “hot potato” speech. But is has never impeded me too much. After my first flap surgery I went back to part-time teaching but have to admit it was hard.
Some people don’t get used to their flap so easily. The flap is too bulky and has to be surgically “debulked”. One man said his flap felt like a wet flannel in his mouth. Some people go from a kiwi accent to a formal British one, I have heard. Personally, I’d rather have a posh accent than hot potato speech.
It’s hard to clean your mouth after a flap. Hard to get to back teeth because there can be scarring and tenderness where the flap is joined to the native tongue. A Waterpik or syringe might be needed to squirt water into the mouth and flush out the larger particles of food.
In my case, an unfortunate development was that my flap forced the native tongue into a gap in my teeth on the good side of my mouth. This part of the tongue turned into a small round red lump with the papillae worn off. Not a good look but out of sight out of mind. At least I don’t have hair on my flap which is not unheard of, especially for men.
The first six months to a year is difficult. It can take a long time for the most superficial wound, on the thigh, to heal. The wrist wound looks red and raw for months until it fades into the innocuous pink. I wore a tennis wrist band for a long time. The tongue flap itself can heal well and even develop some of the the appearance and texture of the rest of the oral mucosa or lining of the mouth – that pink, slimy, mucousy look. But generally it remains whiter than a tongue and can be very white and wrinkled like a hand held in water for a long time. After all, it is skin.
During the time in hospital, the healing can be hard. The wrist looks like raw meat and can get infected and full of fluid. I remember a nurse pressing on my wrist and the fluid squirting up to the ceiling like a putrid fountain. Laughter from the crowd!
The flap in the mouth has to have a good blood supply so right from the start it is checked with a Doppler device that checks its “pulse”. I vaguely remember waking up in IC and someone saying, “That is a viable flap”. Good, I thought. I remember later that it was not healing well in parts, had some “necrotic” (dead) tissue and had to be debrided with what looked like a drill. I have since found that debriding means cutting the wound in a criss cross pattern so that the body wants to heal it fast. It worked. Some people have to have their flaps redone. Rarely.
I had a second flap taken from my right wrist after a recurrence in 2014. It went over my inner cheek (buccal mucosa) and gum/jaw. Although I was four years older and in my late 60s, the whole process went a lot better. Maybe because the transfer of tissue was more superficial than for the reconstruction of a tongue. But now I have two pink wrist scars and on each thigh a square of wrinkly white skin.
Trouble with the tongue flap is that problems can only be dealt with by ENT doctors or staff in the surgical ward. GPs and dentists usually have no experience of these flaps so you need to have a clear line of communication with your team. You need to know who to ring if you have problems with the flap, such as it rubbing against a tooth.
Fortunately, there are taste buds throughout the mouth so a person with a tongue flap can still taste.
Microvascular surgery: Surgery on very small blood vessels such as those only 3 to 5 millimeters in diameter. Microvascular surgery is done through an operating-room microscope using specialized instruments and tiny needles with ultra fine sutures.
Pedicle: a small stalk-like structure connecting an organ or other part to the human or animal body, part of a graft, especially a skin graft, left temporarily attached to its original site.
Papillae: the tiny lumps on the surface of a normal tongue
Here are some notes from medical sites on the net
Microvascular techniques have allowed surgeons to readily transfer tissue from one region of the body to another. In the ideal situation, one must replace tissue lost with tissue that has similar characteristics. In the head and neck, tumor extirpation may result in loss of the thin mucosal covering of the oral cavity, pharynx, or larynx.
The radial forearm free flap is ideal for reconstruction of defects of the oral tongue.
The radial forearm free flap is a versatile flap that includes the volar forearm skin and the underlying soft tissues and fascia containing the radial artery as the perforator. It was first introduced by Yang Guofan in China in 1978. Since then, it has been commonly used as a donor flap for reconstructing the intraoral lining and resurfacing facial and neck defects. It has been used in various sites, particularly for tissue defects remaining after a wide excision of head and neck malignancies. The radial forearm free flap has many advantages, including thin and pliable characteristics, a relatively hairless nature, and a long pedicle with a large external diameter, making it very useful .
Here are some articles about survivors who have successfully lived through this hand to mouth procedure.