FIGURE  5.1 Squamous cell cancer of the tongue appropriate for STSG reconstruction.

Other patients may present with a lesion on the tongue that is often painful locally or has referred pain to the ear or is bleeding. The patient may complain of being “tongue-tied” (dysarthria). If the cancer has impeded their diet, they may complain of either dysphagia or frank weight loss. Because of the robust lymphatics of the ventral tongue and floor of the mouth, even small cancers may have already metastasized. In these cases, the patient may notice a mass in the neck.

A careful history should be elicited, documenting known risk factors such as the use of tobacco and alcohol, recurring trauma from a dental or prosthetic source, and preexisting lesions such as erosive lichen planus. Questions should be asked about other symptoms such as dysgeusia or paresthesias of the tongue, lips, or cheek. Other symptoms to look for include dental issues with pain in the teeth or loose teeth. Additionally, a history that evaluated the patient’s comorbidities is important.

A careful diagnostic evaluation including a staging examination is critical before embarking on aggressive surgical therapy. Any suggestion of cervical lymphadenopathy should be carefully noted and evaluated. As many of these patients have been smokers, a systematic evaluation should include a careful history of pulmonary disease or other coexisting medical conditions that might complicate treatment.

PHYSICAL EXAMINATION

A comprehensive examination of the head and neck is performed with special attention to the tongue including the size of the lesion, the thickness of the lesion, deviation of the tongue on protrusion, tethering of the tongue or reduced mobility, and the cranial nerve examination. Fixation of the cancer to the mandible may imply bone invasion that may influence the reconstructive choices other than the skin graft. Any suggestion of hypoglossal nerve weakness or lingual nerve involvement suggests a larger and more extensive tumor and may imply a more extensive resection, less appropriate for an STSG. A careful assessment of the rest of the aerodigestive tract is indicated to rule out a second primary cancer in patients with a smoking history. The submental, submandibular, and jugulodigastric chains are most commonly involved with cervical metastasis; therefore, a complete examination of the neck is also critical to document lymphatic metastasis. The donor site must be inspected to rule out infection, cutaneous lesions, or indications of previous surgery or radiation.

INDICATIONS

Indications for the STSG include small- or moderate-sized defects with limited involvement of the floor of the mouth. Large defects managed with a skin graft will scar and tether the tongue, which leads to an impairment of speech and swallowing.

CONTRAINDICATIONS

Contraindications to split-thickness skin grafting include tumor-specific and patient-specific factors. Larger tumors are best treated with other techniques such as free tissue transfer with an anterolateral thigh or radial forearm free flap. The complication rate is higher with STSG reconstruction of large oral defects. Specifically, large skin graft reconstructions are prone to wound breakdown, fistula, wound contracture, and poorer functional outcomes such as dysarthria and dysphagia. STSG reconstruction is contraindicated in previously radiated patients. Patient-specific factors such as diffuse skin disease, significant sun exposure, and lack of an appropriate donor site may be rare contraindications to the use of a skin graft.

PREOPERATIVE PLANNING

Imaging Studies

Computed tomography (CT) and/or magnetic resonance imaging (MRI) scans may be used to evaluate the extent of the primary cancer and the regional lymphatics. Historically, the contrast-enhanced CT is the most frequently used form of imaging for evaluating the oral cavity due to its resolution and ability to evaluate for bone invasion. However, dental artifact from metal fillings or prosthesis may compromise its quality in the area of interest. MRI scanning may provide excellent soft tissue resolution of the tongue when there is unacceptable artifact found on the CT scan.

For cancers with advanced T and N stages, examination of the chest and abdomen is important. Historically, CT of the chest and abdomen were frequently used. Currently, PET–CT is increasingly used to stage cancers of the head and neck. This modality is especially useful in lesions with multiple metastatic lymph nodes or inferior level IV lymph nodes where the likelihood of distant metastasis is increased.

Staging Endoscopy

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