Lingual release refers to the separation of the lingual aspect of the mucosal surfaces from the inner aspect of the mandible 270° from the glossotonsillar sulcus on one side, anteriorly around the mandible to the contralateral glossotonsillar sulcus.¹ Although commonly bilateral, unilateral release is appropriate and feasible in certain small tongue or FOM cancers. In most cases, an upper neck dissection is performed prior to the combined approach to allow exposure of the external carotid branches, the lingual and the hypoglossal nerves, and the suprahyoid muscles.

Once the soft tissue and muscular attachments to the mandible are released, the entire tongue and the FOM is “released” and can readily fall into the neck and be visualized and dissected via the neck incisions, rather than transorally. If mandibular resection is not planned, mandibular lingual release may be performed without dissection of the soft tissue envelope overlying the mandible (Fig. 16-38A,B). The digastric, the mylohyoid, the geniohyoid, and the genioglossus muscles are released at their anterior attachments, and subperiosteal dissection is performed along the inner cortex of the mandible. The intraoral mucosa is released at the dental mucosal junction with preservation of the interdental papillae in the dentate patient, or along the superior alveolar crest in the edentulous patient. Following mucosal release, the tongue and the FOM are delivered into the neck. If additional posterior exposure of the base of the tongue or the lateral pharynx is required, the dissection may be extended into a pharyngotomy incision.

The term “visor” is used to differentiate it from an “apron” flap, whereby visor is a bilateral neck and cheek flap elevated cephalad beyond the mandible to expose the body of the mandible bilaterally. Thus, the flap of skin can be considered a visor that nears the upper cheek and eyes. The apron flap, however, is limited in its superior extent, and thus does not reach the level of the cheek but forms an apron over the neck region. In most cases, an upper neck dissection is performed prior to the combined approach to allow exposure of the external carotid branches, the lingual and the hypoglossal nerves, and the suprahyoid muscles.

If mandibular resection is planned, a visor flap is created by subplatysmal dissection extended superiorly over the lateral surface of the mandible. This may, although not frequently, require division of bilateral mental nerves, and patients must be counseled preoperatively regarding the resulting sensory deficit. If the mandible does not require resection on one side, the mental nerve is preserved. As opposed to the “lingual” release where the incision is in the gingival or lingual aspect of the mandible, the “mandibular” release requires a releasing incision along the gingivolabial and gingivobuccal sulcus. When there is no periosteal involvement or tumor growth through the outer cortex of the mandible, the transosseous plate can be placed prior to osteotomy and removed. This may preserve occlusion and cosmesis of the mandibular contour and height. Otherwise, intermaxillary fixation may be necessary to maintain mandibular position for reconstruction. Once appropriate releasing incisions are completed, the mandible, the tongue, and the FOM are delivered into the neck. Tumor is resected with osteotomies in the bone where indicated, and margins are taken peripherally, deep, and in the neurovascular bundle and marrow of the mandible. Particular attention is paid to preservation of the lingual and the hypoglossal nerves when allowable. For large tumors of the tongue, exposure, mobilization, and ligation of the ipsilateral lingual artery in the neck prior to resection may aid hemostasis, and mobilization of the hypoglossal nerve can allow preservation of some branches when oncologically safe. Following resection, the surgical defect is appropriately reconstructed, with particular attention paid to restoring a soft tissue barrier between the OC and the neck. Native FOM musculature or myofascial tissue from the reconstruction flap should be firmly affixed to the mandible, via holes drilled into the bone, if necessary. Additional considerations would include laryngeal and/or hyoid suspension to improve postoperative swallowing function.

The mandibular swing approach refers to a parasymphyseal or midline osteotomy and lip split, which allows the mandible and lip/cheek complex to “swing” laterally, leaving a wide open access to the OC, the retromolar trigone, the deep tongue, the oropharynx, and the parapharyngeal space without limitation by position of the lips, the cheek, or the mandible (Fig. 16-39). Such an approach may also provide access to the upper oropharynx for oral tumors extending into the soft palate, the tonsillar fossa, the glossopharyngeal sulcus, or the base of tongue. A variety of incisions for dividing the lower lip and the chin have been described, including straight line, zigzag, and chin button among others.^3,4 A visible facial scar is unavoidable, but patients who
have been appropriately counseled are generally not dissatisfied with the postoperative appearance.⁵ The most aesthetically and functionally acceptable incisions permit precise reapproximation of the vermilion and the orbicularis muscle layer and include techniques to disrupt the linear scar and minimize contracture⁶ (Fig. 16-40). The lip incision is extended along the mental crease into the neck, where it is joined to the cervical incision to allow broad surgical access. Neck dissection is generally performed at this time, not only for oncologic purposes (if indicated), but also to maximize exposure of the FOM and the posterior OC. In most cases, an upper neck dissection is performed prior to the combined approach to allow exposure of the external carotid branches, the lingual and the hypoglossal nerves, and the suprahyoid muscles. If oropharyngeal exposure is required, this may also be optimized by dissection of the lateral neck.