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Paper text:
the tongue is crucial in pronunciation and the manipulation of the food bolus for mastication , and is critical in prevention of aspiration .
. however , the larger the defect after resection surgery , the greater the morbidity in terms of function .
therefore , microvascular free flap reconstruction usually is required if more than 50% of the tongue is resected .
adequate reconstruction of tongue with a protuberant shape and sufficient volume is important for postoperative function .
the radial forearm free flap ( rfff ) can be applied to any defect of the oral cavity because of its exibility , thinness , and good vascularization .
however , tongues reconstructed with rfff sometimes need revision surgery because inadequate defect measurement at primary surgery can lead to bulkiness and limited movement of the reconstructed tongue .
another limitation of the rfff for tongue reconstruction is a non - esthetic color that does not match adjacent tissues . in this case report
, we present a patient who was treated by defatting vestibuloplasty five years after partial glossectomy and rfff reconstruction .
the skin flap of the patient s tongue over the past five years maintained the original color and texture of the forearm skin , but after defatting the rfff , the color and texture of the skin flap changed gradually to become similar to adjacent tissues .
a 70-year - old female patient was referred to the department of oral and maxillofacial surgery of the gangneung - wonju national university dental hospital to receive vestibuloplasty to fit a mandibular denture .
the patient underwent partial glossectomy and rfff reconstruction for treatment of tongue cancer five years prior .
routine dental examination showed that the alveolo - lingual sulcus of the reconstructed area was almost lost , and the reconstructed portion of the tongue was overcontoured ( fig .
an additional complaint was that her pronunciation was unclear because of the limitation in tongue movement .
we determined to perform the defatting of rfff with vestibuloplasty by a modified kazanjian method .
the flap was repositioned inferiorly and buttons placed percutaneously to secure the flap downward ( fig .
immediately after surgery , to maintain the denture space , a temporary denture was fixed with micro screws for two weeks ( fig .
, additional laserplasty was performed using co2 laser because there were some irregular surfaces under the removable partial denture ( fig . 1 ,
a removable partial mandible denture was fabricated in department of prosthodontics . during the follow - up
, we observed that the texture and color of the reconstructed portion of tongue was gradually becoming similar to adjacent tissues ( fig .
the treatment goal of tongue reconstruction should be the preservation of function such as swallowing , pronunciation and esthetic blending with adjacent tissues .
the rfff can be used in any part of the oral cavity for more functional and esthetic reconstruction .
it creates a neo - tongue with good form and increased bulk posteriorly at the base .
in addition , if the medial and/or lateral antebrachial cutaneous nerves of the flap are coapted to the lingual nerve , sensory return is possible .
the folding techniques used in reconstruction of the tongue with micro - vascular free flaps is useful with recovery of adequate speech and swallowing in most patients .
while rfff reconstruction of tongue has many advantages , it can not fully recover function and esthetics of the tongue .
if surgery is performed with excessive flap volume , revision surgery will be required . in this case
it often takes on an appearance similar to oral mucosa following transfer to the oral cavity .
these changes are thought to be due to inammation resulting from the oral environmental factors such as saliva , oral microora , mechanical and chemical stimuli associated with food ingestion , and candida infection .
the rich blood supply for the skin of the forearm enables the skin to undergo these changes .
histologically , mucosa - like change of rfff does not represent true metaplasia , permanent change in epithelial type .
in many cases these changes are reversible , and seem to be directly related to the degree of inflammation in the dermis . in split thickness skin graft , the skin maintains the epidermal phenotype and does not assume the histologic characteristics of mucosa . in this case , the mechanism of the color change was unclear . it might be a little different from the mechanism of the above cases , because the skin of the rfff was unchanged during the previous five years ( fig .
1 ) . the color change of the rfff did not start until the defatting surgery . during the observation after the defatting surgery
, we saw that the color and texture of the revised tongue changed gradually to become similar with the adjacent tissue ( fig .
, this change might be due to the original healing nature of the transplanted rfff as a response to the severe injury within the flaps from the defatting surgery . also ,
because the stem cells in fat tissue can differentiate into many type of cells , the flap might be affected by stem cells within the subcutaneous fat of the rfff .
after reconstructive surgery for oral cancer , usually we have an opportunity of secondary surgery for implant or bone graft . in that time , defatting surgery may be contribute to make the skin match better .
, there was distinct improvement of pronunciation after using the palatal augmentation prosthesis ( fig .
, we recommend this palatal augmentation prosthesis for the patients whose tongue length is not sufficient for adequate palatal contact . in conclusion , defatting vestibuloplasty may be a useful reconstructive technique for more functional and esthetic reconstruction of the tongue .
we urge cautious interpretation , as the presented case is only a single case and the evidence is limited .
therefore , a well - controlled prospective study is required to examine this phenomenon closely .
the radial forearm free flap ( rfff ) is a thin and pliable tissue with many advantages for tongue reconstruction . 
 however , tongues reconstructed with rfff occasionally need revision surgery because inadequate defect measurement at primary surgery can lead to bulkiness and limited movement of reconstructed tongue . in this case 
 , the patient underwent partial glossectomy and rfff reconstruction for treatment of tongue cancer five years prior . 
 we could not make a lower denture for the patient , because the alveolo - lingual sulcus of tongue was almost lost . 
 so we performed vestibuloplasty with a modified kazanjian method on the lingual vestibule of the mandibular right posterior area , and defatting surgery to debulk the flap . 
 after surgery , we observed that the color and texture of the revised tongue changed to become similar with adjacent tissue . 
 the patient obtained a more functional and esthetic outcome . 
 accordingly , we present a case report with a review of relevant literature .