The Manta Ray Flap

摘要

Sir: Total glossectomy defects are among the most significant challenges in head and neck reconstruction. The tongue’s complex muscular anatomy and function are, at present, irreproducible. Modest achievements in functional outcomes are attributable to the provision of tissue bulk, allowing the neotongue to act as an obturator in the oropharynx.1–3 The multidimensionality of these defects is also difficult to visualize, resulting in a paucity of reports on the technical details and refinements of total tongue reconstruction. We illustrate a novel, reproducible, and adjustable design for total tongue reconstruction termed the manta ray flap, given the resemblance of the skin paddle design to the marine animal bearing the same name. The manta ray flap was performed in our most recent five patients with primary squamous cell carcinoma of the tongue, following total glossectomy and neck dissection. Our flap design for total tongue reconstruction is intended to fit exact recipient-site specifications, without the need for modification once harvested. Our basic template is for the entire tongue, floor of the mouth, and anterior pharynx. Additions and subtractions are made systematically, depending on measurements of the particular defect (Fig. 1). Our flap of choice is the anterolateral thigh fasciocutaneous flap, having the advantages of a long pedicle length; a concurrent two-team approach; minimal donor-site morbidity; and the ability to chimerize with available muscle, nerve graft, and vein graft from the same donor site.4 A template in the shape of the manta ray is created by taking the measurements of both the tongue resection and the remaining defect as described (Fig. 2, above, left and right). The template is then transferred to the donor site with the appropriate pedicle orientation based on the recipient vessel location (Fig. 2, below, left).Fig. 1: (Above, left) The basic template is for the entire tongue, floor of the mouth, and anterior/central pharynx. Additions and subtractions are made depending on the particular defect. The pattern is bilaterally symmetrical like the oropharynx, with the median raphe of the tongue constituting the line of symmetry. The dimensions of the template are determined as follows: (1) A to B, tip of the tongue to the anterior floor of the mouth; (2) B to C, anterior floor of the mouth to the retromolar trigone, (3) C to D, retromolar trigone to the vallecula (or the end of the resection); (4) A to D, the tip of the tongue to the vallecula (or the end of the resection); (5) B to B′, circumference of the tongue at the level of the frenulum, or anterior floor of the mouth; (6) C to C′, width over the dorsum of the tongue at the level of the retromolar trigone (from glossopharyngeal sulcus to glossopharyngeal sulcus). (Above, right) To fold the flap into the three-dimensional structure, A is sewn to A′ for the tongue tip, and B is sewn to B′ to form the ventral surface of the tongue and floor of the mouth. (Below) In the operating room, the measurements described above are converted to an actual template that is sewn together loosely and tacked into the defect to ensure that it fits well in all dimensions.Fig. 2: (Above, left) A typical total glossectomy specimen is shown. The floor of the mouth and pharyngeal components are attached to the specimen itself. (Above, right) Most of these defects involve a significant portion of the floor of the mouth, up to the lingual gingival, as shown here. The defect is through and through to the pharynx. This means that the entire three-dimensional structure of the tongue and floor of the mouth must be recreated, including their interface and smooth transition to the pharyngeal walls. (Below, left) The template is transferred to the thigh with measurements as described in Figure 1. The flap is oriented so that the vessels exit close to where the floor of the mouth portion meets the pharyngeal portion of the template, on the side where recipient vessels have