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With the advent of microsurgery fasciocutaneous free flaps have become a well known and accepted option for the repair of tongue defects. Many authors have tried to recover tongue function by modifying this approach. An innovative method for the repair of tongue defects using an adipofascial anterolateral thigh free flap is presented in this paper. The results are compared with those of tongue reconstructions implementing traditional fasciocutaneous free flaps performed at our institution. The histological features of the flaps were investigated postoperatively. Although this preliminary report has to be confirmed by further experience, it seems to solve many tongue-reconstruction related problems.
The restoration of the function of the highly specialised tissues of the tongue is one of the great challenges for the plastic surgeon. Until the advent of microsurgery, patients with major tongue defects were treated with local flaps
In the past 15 years, the fasciocutaneous forearm free flap has been the flap most used for tongue reconstruction. Its pliability and thinness make it ideal for use in oral cavity defects.
In some cases, the reconstruction of more than half a tongue has been attempted using the reinnervated rectus abdominis myocutaneous flap. However, no taste sensitivity can be recovered using these flaps and protective sensation recovery never reached a satisfying level.
This article puts forth a new approach to tongue reconstruction using an adipofascial anterolateral thigh flap.
1. Case report
In May 2001, a 50-year-old man presented with a squamous cell carcinoma of the mobile right tongue border (Fig. 1) . Clinical examination of the neck was negative. The patient underwent resection of the mobile right half part of the tongue with conservative neck dissection. A 13×6.5 cm2 anterolateral fasciocutaneous thigh flap supplied by an 8 cm vascular pedicle was harvested from the right leg (Fig. 2) . During the procedure, the flap was converted into an adipofascial flap, the skin excised and trimmed to fit the tongue defect. Then the flap was sutured to the residual tongue in a reverse fashion with the fascial surface outward. The artery and vein were anastomosed end to end to the superior thyroid artery and the external jugular vein (Fig. 3) . The thigh defect was closed directly.
Fig. 1The carcinoma of the right border of the tongue.
The 13th day after surgery, the patient had a pulmonary embolism due to left popliteal vein thrombosis and underwent thrombolitic therapy. Regarding the reconstruction, no surgical complication occurred in the postoperative period. The donor site wound healed uneventfully. The patient was discharged with a soft diet on day 30. His speech was rated intelligible. Forty-five days after surgery the clinical aspect of the reconstructed tongue was identical to the residual tongue. Its mobility was limited in tip protrusion, but it was able to transfer a bolus to the pharynx at will, and the patient did not require head-tilting to swallow (Fig. 4) . The hot and cold and touch sensitivity of the neo-tongue did not differ from that of the residual tongue and even taste sensitivity was recovered. The physical aspect of the flap resembled that of a normal tongue with taste buds covering the mucosa. The result of the biopsy of a specimen of the neo-tongue compared to the biopsy of the residual tongue did not show any relevant difference. Both specimens showed a squamous epithelial lining, and a mild inflammatory infiltrate was present in the lamina propria (Fig. 5) . Small stromal nerve structures were detectable in both biopsy specimens using an immunohistochemical staining for S-100 protein (Fig. 6) .
However, taste sensation has never been tested because the flap's epithelium lacked the taste buds which cover the tongue mucosa. In some cases, a mucous membranous metaplasia of the fasciocutaneous flap used for tongue reconstruction has been observed one year after surgery, but there was no regeneration of taste buds and the patient was unable to recognise taste on the flap.
The transfer of free microvascular jejunal patches was attempted to reproduce a mucous producing mucosa, but its harvest is complicated when compared with the fascial flaps.
Many authors studied the remucosalisation of the myofascial pectoralis major flap used to cover oral mucosa defects and their histological results showed that the flap was covered with a thin layer of squamous mucosa 1 month after surgery. This result was not influenced by the subsequent radiotherapy treatment.
Later, when the practice of using a fasciocutaneous radial forearm free flap for oral cavity reconstruction was well established, the idea of fascial flap prelamination was proposed,
but delayed tumor resection should usually be avoided.
At our institution, we used to perform tongue reconstruction using the forearm free flap according to Soutar's technique. All cutaneous flaps give the tongue a patching aspect since their surface continues to be constituted by a hairy keratinized epithelium. In two cases, forearm cutaneous flaps resembled a normal tongue due to their pinkish color three months following surgery (Fig. 7) . Radiotherapy was administered to both patients in the post-op period and the biopsy of the flaps showed the presence of inflammatory cells in the context of a keratinized epithelium, but no mucosa regeneration was observed.
Fig. 7Normal tongue appearance of the forearm free flap used for tongue reconstruction after radiotherapy treatment.
We chose the anterolateral thigh free flap for tongue repair because of the low morbidity of the donor site. When excising the skin from the flap, we found the thick and strong fascia an ideal field for allowing the lingual mucosa to spontaneously regenerate, avoiding the patching aspect of the cutaneous flaps, and obtaining better functional results.
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